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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232 (209)4BB-3420 <br /> NON-REFUNDABLE PERMIT .8 OV Or lehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS SEC ol'E.Kettleman Ln&Heckman Rd CITY IP Lodi,CA <br /> A' / u� D <br /> CROSS STREET �O�V APN U I'� X.7�`ZX&ARCEL SIZEtt LAND USE APPLICAT10NN# A <br /> OWNER NAME �i Z9/7Vi r � / f 5 f vc_�+2 lC ,' K it;?r 2/Y <br /> F I V)LY"r[l I PHONE-r Q �! / )_-YT <br /> S y <br /> OWNER ADDRESS _�(� / .fD fl kG1 E111li L� CITYISTAMrZV J7 71,6 <br /> CONTRACTOR (CMT Engineering Z -'y�t'dR .rty PHONE 801-908-5854 <br /> CONTRACTOR ADDRESS 2796 S.Redwood Rd CITY/STATEZP West Valley City,LIT 84119 <br /> SUBCONTRACTORICONSULTANT Cascade Drilling PHONE 916-638-1169 <br /> SUBCONTRACTORICONSULTANTAODRES5 3000 DLlllltl]St, C1ITY/STAAT�7EZP West Sacramento,,CA 956911 <br /> LICENSE XC-57 C$1 II D-09 1,Other NUMBER 1058336 EXPIRATION DATE //30/2021 <br /> BILLING PARTY: LI OWNER 'CONTRACTOR I SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:I_l General Mineral/Coliform Bacteria(4391)1 Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE it Domestic/Private -1 Irrigation/Agricultural (I Industrial Water Quality Monitoring X Soil Sampling/Characterization <br /> D Public Water System <br /> if different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK D New Well I Replacement Well I I Well Alteration/Modification D Other <br /> MonitoringWell(s) #of wells I1 Soil Boring(s) 0ofbedees XGeotechnical 7 ofborings <br /> Out-Of-Service Well I I Out-Of-Service Well Renewal D Cross-Connection Repair <br /> New Pump Pump Replacement Pump Repair f_Raise Well CasbrKt <br /> WELL CONSTRUCTION <br /> Drilling Method D Mud Rotary Air Rotary XAuger 1 Cable Tool Push Point Other <br /> Proposed Well Depth�j f-70_it Excavation 5 in diameter J Open Bottom Gravel Pack/Gravel Size m diameter <br /> fl Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM SchedI Steel 11 Plastic I Stainless Steel Cl Other <br /> Grout Seal Deptf��- eft XNeat Cement(94 lb bag/5-10 gal water) ❑Sand Cement sack rnix/7 gal water <br /> i I Bentonite(20%solids) Other <br /> Grout Placement Method X Pumped D Free Fall X 01her 71 Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller i I Pump Contractor I Other <br /> I Concrete Pedestal[]Dimensions.Width ft Length ft Thick in :Christy Box i,Stove Pipe <br /> PUMP Submersible)I Turbine I I Other I{p pump Set ft Standing Water Level it <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 /> MI IMU 48 HO R ADVANCE N TICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TRLE Opertaions Manager DATE 2/7/20 <br /> S V <br /> ryOE rI,�FM�IJhr�Y <br /> p�Rr�FNr <br /> #I—I I# <br /> �EA ENTT U�Y <br /> Application Accepted By te � � ArEa--���—'—`— Employee IDN'C�"�"'__ <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By `` Date WAIVER Received <br /> Soil Boring Inspection By `1u� i7�)-.r; Date ?(J V Constructed Well Depth It <br /> COMMENTS i <br /> PE Sc Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info - Cash emitted Service Request tl <br /> 0 <br /> EF1043-06 8/1112019 ��' WE'_I.P„',I F•FF tif.11' <br />