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} <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)468-3420 <br /> NON-REFUNDABLE PERMIT WWW.S Ov.Or /ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS South Interlaken DriveCITVILP Lodi/95242 m <br /> a <br /> CROSS STREET South Lower Sacramento Road re W or Sne APN 027-410-01 PARCEL SIZE 8.46 ACS LAND USE APPLICATION# o <br /> OWNER NAME Bennet Land Investments /ou III: 'ez 0�ju�y�GL(� , PHONE N <br /> OWNER ADDRESS P.O. Box 1597 CITYISTATE/ZIP Lodi/CA/95241 <br /> CONTRACTOR West Coast Exploration PHONE (209)985-7541 <br /> CONTRACTOR ADDRESS 1540 Roosevelt Avenue CITY/STATEMI,Escalon/CA/95320 <br /> SUBCONTRACTORICONSULTANT CTE CAL Inc. PHONE (209)543-1799 <br /> SUBCONTRACTOR/CONSULTANT ADDRESS 4230 Kiernan Avenue,Suite 150 CITY/STATE/ZIP Modesto/CA/95356 <br /> LICENSE x C-57 C-61 D-09 Other NUMBER 670761 ExPIRATION DATE 1/31/2020 <br /> BILLING PARTY: OWNER J CONTRACTOR x SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domeslic/Pnvate Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Charactenzalion <br /> Public Water System <br /> If different from Owner Water System Name Contact Name or Phone Number <br /> TYPE OF WORK 7 New Well Replacement Well Well Alteration/Modification xOther <br /> 0 Monitoring Well(S) #of wells Soil Boring(s) #or borings It Geotechnical 3 #of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pum 0 Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary 0 Air Rotary x Auger Cable Tool Push Point Other <br /> Proposed Well Depth 15 ft Excavation 4 in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched Steel -1 Plastic Stainless Steel Other <br /> Grout Seal Depth It Neat Cement(94 lb bag/5-10 gal wafer) D Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped Li Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller C: Pump Contractor Other <br /> 0 Concrete Pedestal Dimensions:Width ft Length ft Thick in Christy Box Stove Pipe <br /> PUMP ❑Submersible Turbine Other HP Pump Set 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. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> INIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)9J537-769{7 <br /> SIGNED JZ TITLE SrJ "� "—`�.(�15 3 DATE <br /> S E JE I AIT T A C JH JE D L O IC JAIT I O N M A P <br /> I I <br /> 2019 <br /> 9,p <br /> N <br /> )Y"14 4LRTMENT <br /> PJRTMENT UjtE 0 LY <br /> Application Accepted By Date (/v Area / Employee ID# <br /> Grout Inspection By Date PECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By /295%LIL.''LDate Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received he Amount Date PerrnlU Invoice# Well IDN <br /> 2odeE Info s Fiernitted 5erviU Re uest# <br /> 1Z�ri <br /> EHD 43-06 6/11/2019 <br /> 77 � � `� WELL/PUMP PERMIT <br />