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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 186a EAST HAZELTON AVENUC-STOCKTON CA 95205-(209)466-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS CrryI21P <br /> LODI,CA 95242 (M <br /> D <br /> CROSS STREET APN 055-020-020-066 PARCEL SIZE 12.0 LAND USE APPLICATION A 612 <br /> m <br /> OWNER NAME GRINDSTONE JOE ASSOCIATION PHONE (650)279-0242 H <br /> OWNER ADDRESS 1029 N COUNTRY CLUB BLVD. CITY/STATEmP STOCKTON.CA 95204 — <br /> CONTRACTOR DREW&HEFFNER WATER WELLS&PUMPS _ PHONE (559)645-2483 __ CD <br /> CONTRACTOR ADDRESS 26452 AVENUE 17 112 CITV/STATEmP MADERA,CA 93638 <br /> SUBCONTRACTOR ._ PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/LP = <br /> LICENSE ✓C-57 C-61 0-09 Other NUMBER 1003754 EXPIRA11ONDATE 05131/2021__ <br /> DOMESTIC WELL SAMPLING:✓General Mineral/Coliform Bacteria(4391)✓Dibromochloropropane(4392)✓Arsenic(4393) <br /> INTENDED USE Domestic/Private Irrigauon/Agneullur.1 Industnal Water Quality Monitoring Soil Sampling/Characienzatior # <br /> Public Water System _ -- --- - CD <br /> 11 Shce—i from Owner Wager V_ <br /> Nnma (Pniaa Name m Pl,dte NumM+i O <br /> r <br /> TYPE OF WORK New Well Replacement Well Well Allerauo,Wodd:CaUon Other _. _ _.--_ _._...__._...._.__.-_.__._.._.. Q <br /> Monitoring Wells) p of wells Sod Boring(s) a PI51Onya Geotecnn¢al___.._ .r O <br /> Out-Of-Service Well Out-Of-Semtce Well Renewal Cross-Connection Reoav <br /> ✓New Pump Pimp Replacement Pump Repair Raise Well Casing y <br /> WELL CONSTRUCTION CD <br /> Drilling Method✓Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br /> N <br /> Proposed Well Depth 200 h Excavation 12 in diameter Open Bottom ✓Gravel Pada/Gravel Size 0094.0 375 in diameter -A <br /> N <br /> Conductor Casing in diameter i Conductor Casing Depth It <br /> Well Casing Diameter #—in Thick auge/ASTM Schad SDR 17 Steel ✓Plastic Stainless Steel Other! _ <br /> Grout Seal Dept sat Cement(94 lb bag/5.10 gat water) ✓Send Cement- 10.3 —sack mixR gal water <br /> Bentonite(20%solids) Other -------- <br /> Grout Placement Method✓Pumped Free Fall Other Retardant/Accelerator(name( <br /> OESTAL In tailed By Drdlar Pump Contractor Other <br /> Concrete Pedestal✓Dimensions Width 4 ft Length 4 ft Thick L - -n Christy Box Stove Pipe <br /> PUMP Vsubmersible T r HP IPump Set 4s It Standing Water Level It <br /> 1 H Y THAT 1 VE PREPARED 5 APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> AQUIN COUNTY RDIN CES, STATE LAWS, D RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTT W THE CALIFORNIA C NTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENS O LAWS. <br /> MINIMUM d HO ADVANCE REQUIRED FOJR111NSPEECrTI_ONNSS-PLEASE CALL(2095 7697 1 <br /> TTt Ii V nJ 1 w Onn_ a <br /> IGNED 1 _ — -- - l <br /> - - - f _ <br /> __ - - PAYMENT <br /> - - - RECEIVED <br /> - <br /> - - X252019 <br /> AN JOAQUIN COUNTY <br /> VIRONMENTAL <br /> ifjiITN OTPARTMENI <br /> I <br /> Application Accepted By __ ESP R T M E NT . .,E- O L Y Arra _ Emplr:yse I <br /> nM?0�� <br /> ael/ <br /> Grout Inspection By hDace PECIAL Well Permit <br /> Pump Inspection BY—__ ____._ Date WAIVER Received—_,—__ <br /> Sod Boring Inspection By Do= ConstmciedjXell Depth <br /> Tre- <br /> SWL 1-- I�_ lNI Y iU/` <br /> PE SC Received Check#I Amount at Permit/ Invoice A —Well IDA 5U <br /> Codes Info Cash Remitted ervice Re uestA <br /> — - <br /> ---- Giro r <br /> 1 '! B1E. --- - - -- -- <br /> - - _ 0- <br /> rr) <br /> 141'_ 'SUMP PERmr <br /> 7/30/17, Ricca u7blat two -"-r,f �iVP1g'f Af "''�° 27 -& <br /> 'Co 6fl ' — 0 , ��a l(a r al"17/ /0 . 3 sem. <br />