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WELL/PUMP PERMIT <br /> ' SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232 (209)466-3420 <br /> NON-REFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> (A <br /> JOB ADDRESS 5699 W. Turner Rd. CITY/ZIP Lodi, CA 95242 <br /> m <br /> D <br /> CROSS STREET HWY 5 �(114-61, APN 01116023 PARCELSIZE����LAND USE APPLICATION# o <br /> A <br /> m <br /> OWNER NAME Matt Lauchland PHONE (209)481-1315 w <br /> OWNER ADDRESS 5271 W. Turner Rd. CITYISTATE2IP Lodi, CA 95242 <br /> CONTRACTOR AG Inc DBA Lodi Pump and Irrigation PHONE (209)368-5082 <br /> CONTRACTOR ADDRESS 1301 E. Armstrong Rd, CITY/STATE2IP Lodi, CA 95242 <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTORICONSULTANT ADDRESS CITYISTATEMP <br /> LICENSE - C-57 x C-61 D-09 Other NUMBER 739462 ExPIRATIONDATE 8/31/21 <br /> BILLING PARTY: OWNER X CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private x 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 New Well _ Replacement Well Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells Soil Boring(s) #of borings Geotechnical #of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> _ New Pump x Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point L Other <br /> Proposed Well Depth ft Excavation 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 1 Steel Plastic I Stainless Steel J Other <br /> Grout Seal Depth ft Neat Cement(941b bag/5-10 gal water) _i Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method I Pumped _.1 Free Fall .Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller �Pump Contractor Other <br /> Concrete Pedestal ,Dimensions:Width ft Length It Thick in Christy Box Stove Pipe <br /> PUMP Submersiblex Turbine _.Other HP 50 Pump Set -5' It Standing Water Level 16 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 /> 1�r\�N)IMUM 48 HOUR AE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209))953-7697 <br /> SIGNED d� � ^�7 TITLE DATE J-t, fe-Zo <br /> IAl <br /> //p <br /> EPARTMENT USE NLY / 1y <br /> Application Accepted By �Z'Z Data 3 z �Zb Area Employee ID# <br /> Grout Inspection By f Date SPECIAL Well Permit <br /> Pump Inspection Byi TAInr-5� l��Oe.y'a �_ Date , a a/2D S WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Cash Remitted Se c Re uest# <br /> Wit Oso $ 7 4.t/ <br /> EHD43-06 6/11/2019 WELL/PUMP PERMIT <br />