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WELL/PUMP PERMIT <br /> i SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)468-3420 <br /> NON-REFUNDABLE PERMIT www.s. OV.Of /ehd 12EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS Iris Court South of Iris Drive CITY/ZIP Lodi/95242 m <br /> D <br /> CROSS STREET Ins Drive is N of Site APN 033-041-1'7 PARCEL SIZE 2 ACS LAND USE APPLICATION# o <br /> OWNER NAME ("'naj C(L (.,Jeno ) PHONE y <br /> I <br /> OWNER ADDRESS • D :5+A[I ion CITY/STATE/ZIP <br /> CONTRACTOR West Coast Exploration PHONE (209)985-7541 <br /> CONTRACTOR ADDRESS 1540 Roosevelt Avenue CITY/STATE/ZIP 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 870761 EXPIRATION DATE 1/31/2020 <br /> BILLING PARTY: OWNER CONTRACTOR X SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK D New Well Replacement Well Well Alteration/Modification 2 Other <br /> ❑Monitoring Well(s) #of wells Soil Bonng(s) #of borings x Geotechnical 2 #of borings <br /> �71 Out-Of-Service Well Out-Of-Service Well Renewal ;Cross-Connection Repair <br /> D New Pump Pump Replacement Pump Repair _i Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ,Mud Rotary 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 _'Plastic Stainless Steel 0 Other <br /> Grout Seal Depth It Neat Cement(94 Ib bag/5-10 gal wafer) D Sand Cement sack mW7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> 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. I 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 /> MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> ..-PLEASE CALL(209)953-7697 II <br /> SIGNED / '�IYL��'�� TITLE ��`" ` ��YLr"�Ji 5} DATE 714 <br /> S I E I E I JAIT IT A C H E D I L O C A T I O N IM A P <br /> � gyMF <br /> Ro 2019 <br /> c <br /> OFAgR��uhj}, <br /> HT <br /> kR MENT U E O LY <br /> Application Accepted By to Area Employee ID# <br /> _t, <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date `)p WAIVER Received <br /> Soil Boring Inspection By ,,kv -+'L— Date / Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Che Amount Permit/ <br /> ode Info as itte to Service Request# Invoice# Well ID# <br /> L11 IR vj <br /> EHD 43-0fi 6/11/2019 /���_^O 71 WELL iPUMP PERMIT <br />