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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.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 14226 N Lower Sacramento Rdy <br /> CITYIZIP Lodi � <br /> CROSS STREET W Century Blvd APN 05823024PARCEL SIZE46 acrel-AND USE APPLICATION# o <br /> OWNER NAME City of Lodi PHONE 209-333-6742 w <br /> OWNER ADDRESS 221 West Pine Street,P.O.Box 3006 CITY/STATE/Z1P Lodi,CA 95241-1910 <br /> CONTRACTOR Geocon Constultants,Inc. PHONE 916-852-9118 <br /> CONTRACTOR ADDRESS 3160 Gold Valley Drive,Suite 800 CITY/STATE/ZIP Rancho Cordova,CA 95742 <br /> SUBCONTRACTOR/CONSULTANT V&W Drilling,Inc. PHONE 209-469-7700 <br /> SUBCONTRACTORICONSULTANT ADDRESS 1133 Blackhurst Drive CITY/STATE/ZIP Galt,CA 95632 <br /> LICENSE X C-57 C-61 D-09 I Other NUMBER 720904 EXPIRATION DATE 4/30/2020 <br /> BILLING PARTY: 11 OWNER : CONTRACTOR :- SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:i 1 General Mineral/Coliform Bacteria(4391)2 Dibromochloropropane(4392)a Arsenic(4393) <br /> INTENDED USE I Domestic/Private Irrigation/Agricultural -1 Industrial F]Water Quality Monitoring Soil Sampling/Characterization <br /> i Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK L_'.New Well :1 Replacement Well ❑Well Alteration/Modification C Other <br /> 1.Monitoring Well(s) #of wells L Soil Bodng(s) #of borings x Geotechnical 5 #of borings <br /> i Out-Of-Service Well L Out-Of-Service Well Renewal L Cross-Connection Repair <br /> L New Pump I Pump Replacement ❑Pump Repair J Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method I I Mud Rotary C1 Air Rotary ri Auger L1 Cable Tool L-Push Point L Other <br /> Proposed Well Depth 15 to 30 ft Excavation 8 in diameter L Open Bottom I I Gravel Pack/Gravel Size in diameter <br /> I I Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched L Steel ij Plastic ❑Stainless Steel l Other <br /> Grout Seal Depth 15 to 30 It X Neat Cement(94/b bag/5-10 gal water) 1 Sand Cement sack mix/7 gal water <br /> Il Bentonite(20%solids) ❑Other <br /> Grout Placement Method L Pumped X Free Fall L Other G Retardant/Accelerator(name) <br /> PEDESTAL Installed By ii Driller I;Pump Contractor ❑ Other <br /> I Concrete Pedestal:_IDimensions:Width ft Length ft Thick in ❑Christy Box 1 Stove Pipe <br /> PUMP i Submersible 1 Turbine 1-;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. PrA�'-I <br /> M 48 H DV C NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED _ TITLE Sr.Staff Engineer DATE 1/31/2020 CV I <br /> D <br /> Z®20 <br /> ORoNM�ouloy <br /> DEpAR MFNT <br /> AR MENT U E 9NLY <br /> Application Accepted By to0 Area Employee ID# <br /> Grout Inspection By Date SSPECIAL Well Permit <br /> Pump Inspection By Date J WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received j CLeck&p Amount Date Permit/ Invoice# Well ID# <br /> odes Info By, Remitted Service Re uest# <br /> n <br /> EHD43-06 6/112019 WELL/PUMP PERMIT <br />