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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 2091 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> ^ e to <br /> Joe ADDRESS Sylvia Drive and Fairmont Avenue Lodi,CA <br /> S�'V tt I CITY12ip m <br /> r a <br /> CROSS STREET E0 Ir V"04 APN c�330801 CL_PARCEL SIZE r 88 LAND USE APPLICATION# A <br /> m <br /> OWNER NAME RDR Buildings PHONE 209-368-7561 u <br /> OWNER ADDRESS 1606 W.Kettleman Lane#F CITY/STATE/ZJP Lodi,CA 95242 <br /> CONTRACTOR Krazan&Associates.Inc. PHONE 559.348.2200 <br /> CONTRACTOR ADDRESS 215 W.Dakota Avenue CITY/STATE/ZIP Clovis,California 93612 <br /> SUBCONTRACTOR Krazan&Associates,Inc. PHONE 559.348.2200 <br /> SUBCONTRACTOR ADDRESS 2.15 W.Dakota Avenue CITY/STATE/ZJP Clovis,California 93612 <br /> LICENSE /C-57 C-61 17 D-09 F Other NUMBER 499908 EXPIRATION DATE 10.31.2020 <br /> DOMESTIC WELL SAMPLING:it General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE i Domestic/Private i 1 Irrigation/Agricultural 'j Industrial 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 C New Well I.. Replacement Well I I Well Ateration/Modification I Other <br /> L Monitoring Well(s) #of wells h,Soil Boring(s) #of borings Geotechnical 8 #of borings <br /> Out-Of-Service Well I Out-Of-Service Well Renewal Cross-Connection Repair (10-50 Feet) <br /> 5 New Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method G Mud Rotary I Ar Rotary Auger i Cable Tool -i Push Point Other <br /> Proposed Well Depth ft Excavation in diameter f11 Open Bottom i Gravel Pack/Gravel Size in diameter <br /> I Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched Steel Plastic I I Stainless Steel I Other <br /> Grout Seal Depth ft VNeat Cement(94 Ib bag/5-10 gal water) I Sand Cement sack mix/7 gal water <br /> I Bentonite(20%solids) l_ Other <br /> Grout Placement Method .I Pumped Free Fall I Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By 5 Driller 5 Pump Contractor Other <br /> Concrete Pedestal i iDimensions:Width It Length ft Thick in Christy Box Stove Pipe <br /> PUMP ri Submersibles_Turbine ri 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 /> UM 48 HOU DVA CE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED T� Managing Engineer DATE 04/17,12020 <br /> F yMF <br /> cE��or <br /> ilrq,IQ <br /> Ij/ <br /> 'r, EP4 Co Lvry <br /> NT <br /> TEL— <br /> DEPARTMENT7USE ONLY <br /> Application Accepted By � Date 7Z'D Area Employee ID# PA <br /> Grout Inspection By Date 1 SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Insped n By Date w C strutted Well Depth It I <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permit] Invoice# Well ID# <br /> Codes Info Remitted S rvice Re uest# <br /> '13 12 IS-0 so !- <br /> EHO 43-06 revised 4114/18 WELL/PUMP PERMIT <br />