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WELL/PUMP PERMIT 1 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205.6232(209)468-3420 1 <br /> NON-REFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> Joe ADDRESS " W Kettleman Ln and Tienda Dr CITY/ZIP Lodi <br /> J.Owe/ .Sgt rp�'"t` 05814035 n <br /> CROSS STREETg-n-.r'Tf-r-=, AP PARCEL SIZE1 2.45 GLAND USE APPLICATION# p <br /> OWNER NAME Browman Development Company PHONE 925.588.2219 y <br /> OWNER ADDRESS 1556 Parkside Drive CITYISTATE/ZIP Walnut Creek, CA 94596 <br /> CONTRACTOR Neil O'Anderson Associates PHONE <br /> + 209.367.3701 <br /> CONTRACTOR ADDRESS 902 Industrial Way CIN/STATE/ZIP Lodi, CA, 95240 <br /> SUBCONTRACTOR/CONSULTANT same as above PHONE same as above <br /> SUBCONTRACTOR/CONSULTANT ADDRESS same as above CITYISTATE/ZIP same as above <br /> LICENSE X C-57 C-61 CI D-09 I I Other NUMBER 46601714 EXPIRATION DATE 05/31/2021 <br /> BILLING PARTY: OWNER X CONTRACTOR D 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 X 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 D Replacement Well D Well Alteration/Modification ❑Other <br /> L Monitoring Well(s) #of wells ❑Soil Boring(s) #df borings X Geotechnical 4 #of borings <br /> Out-Of-Service Well a Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pum Pump Replacement D Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method D Mud Rotary -1 Air Rotary X Auger Cable Tool Push Point Other <br /> Proposed Well Depth 6-25' ft Excavation 4"-6" in diameter Open Bottom D Gravel Pack/Gravel Size in diameter <br /> 1 Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad Steel ❑Plastic �J Stainless Steel -Other <br /> Grout Seal Depth 5'-25' it X Neat Cement(941b bag/5-10 gal water) -i Sand Cement sack mixfl gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped X Free Fall -Other !I Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller D Pump Contractor _i Other <br /> i Concrete Pedestal I Dimensions:Width ft Length ft Thick in D Christy Box D Stove Pipe <br /> PUMP SubmersibleOTurbine -_!Other HP Pump Se[ 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 /> MIN TMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED �C� 'K IJAn TITLE Staff Engineer DATE 5/29/2020 <br /> Y <br /> AA <br /> Al <br /> FMFNr <br /> �Fo <br /> 2?0�0 <br /> V?� <br /> MFN�, <br /> DEPARTMENT USE ONLY J <br /> Application Accepted By ` Date a? ZoTO Area Lad; Employee ID# DA <br /> Grout Inspection By Date _; SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspectio By Date Wim" Constructed Well Depth ft <br /> COMMENTS -ri �e vA 11906e ,-,-eOf im <br /> 4eef ®r flb i-JAW Ls plegent .,,4 thf borphlole. <br /> t70 <br /> SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Info Cash Remitted Service Re uest# <br /> PE <br /> v o o s <br /> EH0 43-06 6/112019, 10163 q22—3 WELL/PUMP PERMIT <br />