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20937.:.;, <br />Will UP PERMIT t`_C I <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue�(- <br />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS 116 <br />MEM32 - (209) 468-3420 <br />jRR %ROM DATE ISSUED <br />JOB ADDRESS 12751 Thornton Rd CITY/ZIP Lodi 95242 <br />CROSS STREET 1-5 <br />OWNER NAME City Of LOCM <br />OWNERADDRESS 221 W. Pine St. <br />APN 055-13-016 PARCEL SIZE 1 6 0 LAND USE APPLICATION # <br />PHONE 209-625-6933 <br />CITY/STATE/ZIP Lodi CA 95240 <br />CONTRACTOR Delta P=p_QmncxmnN ARMAT IRF & MOTOR WORKS ff0Q. 209-466-9625 <br />CONTRACTOR ADDRESS 646 S. California Street CITY/STATE/ZIP Stockton, CA 95203 <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS <br />LICENSE . 0 C-57 X C-61 <br />❑ D-09 0 Other, <br />CITY/STATE/ZIP <br />NUMBER 724778 _ <br />EXPIRATION <br />08/tr <br />LiEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br />INTENDED USE 0 Domestic/Private 0 Irrigation/Agricultural tk Industrial 0 Water Quality Monitoring ❑ Soil Sampling/Characterization <br />0 Public Water System <br />If different from Owner: a er ys em ame Uuntact Name or Prione Number <br />— "VI! u Rapiacement vveii u wen Alteration/Modification 0 Other <br />0 Monitoring Well(s) # of wells 0 Soil Boring(s)# of borings gs ❑ Geotechnical #ofborings <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />❑ New Pump 0 Pump Replacement CK Pump Repair 0 Raise Well Casing <br />WELL CONSTRUCTION <br />Y <br />Drilling Method ❑ Mud Rotary 0 Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point 0 Other <br />Proposed Well Depth ft Excavation in diameter 0 Open Bottom ❑ Gravel Pack/Gravel Size A� in diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched 0 Steel 0 Plastic 0 Stainless Steel 0 Other <br />Grout Seal Depth ft 0 Neat Cement (94 Ib bag/5-90 gal water) ❑ Sand Cement sack mix/7 gal water <br />❑ Bentonite (20% solids) 0 Other <br />Grout Placement Method ❑ Pumped 0 Free Fall 0 Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor 0 Other <br />C Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑ Christy Box 0 Stove Pipe <br />PUMP %Submersible❑ Turbine ❑Other HP Pump Set 8 5 ft Standing Water Level ft <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br />SIGNEDK TITLE CEO DATE 12/06/2018 <br />EP RTMENT USE 0)4L <br />Application Accepted ByDate <br />Grout Inspection By t� Date <br />Pump Inspection By _�`� QiL 1J �t �Ob W`)'\Date_`,_t� <br />Soil Boring Inspection By Date <br />COMMENTS <br />Area VvV ( Employee ID# I <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth ft <br />PE <br />SC <br />Received <br />Check#/ <br />Amount <br />Permit/ <br />Codes <br />InfoDate <br />Remitted <br />Service Re uest # Invoice # Vllfpl►:�p# <br />EHD 43-06 <br />8/04/08 WELL /PUMP PERMIT <br />m <br />D <br />0 <br />D <br />In <br />In <br />N <br />F- ~ <br />Z <br />J <br />W <br />0Z� <br />U Lu <br />Zg <br />d <br />000 <br />o>� <br />Z <br />LU <br />x <br />