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WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1866 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)468-3420 NON-REFUNDABLE PERMIT www.sjgov.org/ohd EXPIRES 1 YEAR FROM DATE ISSUED r \Ssjjlil JDBADDRE33 255Lr .) Y\\ P'lcly nc,l cC J*NcC Lc4-7 CITY/ZIP Ac.tttA I�t!.i Clcj�)2c) C I ' APN 00540007 CROSSSTREET_ �C'�I �-r � �1• PARCEL$IZE�_LAND USE APPLICATION# 2 7 p _ OWNER NAME Sara Lct n T 2 PHONE :?o ^�� 3 c�( 15 OWNER ADDRESS 847 N Cluff Ave Ste B1 CITYISTATF/ZIP_Lodi, CA 95240 -; CONTRACTOR S,1 Ile y PHONE 2.7 79 } •� CONTRACTOR ADDRESS T—gcx— Crrr/STATE/ZJP SUBCONTRACTOR/CONGULTANT PHONE SUBCONTRACTOR/CONSULTANT ADDRESS CIITY/STATEZP LICENSE AC-57 0 C-61 0 D-09 0 Other NUMBER -Ia �y_ EXPIRATION DATE 1 BILLING PARTY: ❑OWNER (CONTRACTOR ❑ SUBCONTRACTOR/CONSULTANT \�� DOMESTIC WELLSAMPUNG:❑General Mineral/Coliform Bacteria(4391)❑Dibromochloropropane(4392)❑Arsenic(4393) CF�VNT INTENDED USE )k Domestic/Private ❑Irrigation/Agricultural ❑Industrial El Water Quality Monitoring ❑Soil Sampling/Characterization e+D ❑Public Water System If different from Owner: Water System NameContact Name or Phone Number TYPE OF WORK New Well ❑Replacement Well 0 Well Mteralion/Modification 0 Other Alpi 2 0 1010 ❑Monitoring Well(s) #of wells ❑Soil Boring(s) or borings ❑Geo RIJ Out-Of-Service Well ❑Out-Of-Service Well Renewal F1 Cross-Connection Repair HED NMECOU N T y1?�New Pum O Pum Replacement ❑Pum Repair 0 Raise Well CasingEACTH IDARNTALWELLCONSTRUCTION TMENT Drilling Method';.Mud Rotary ❑Air Rotary ❑Auger 0 Cable Tool 0 Push Point ❑ Other Proposed Well Depth X45 ft Excavation 12 in diameter ❑Open Bottom Gravel Pack/Gravel Size 1/A in diameter ❑Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched C 1-71 1i; ❑Steel >,Plastic 0 Stainless Steel ❑Other Grout Seal Depth I L( It 0 Neat Cement(94/b bag/5-10 gal water) Sand Cement I j .:� sack miW7 gal water ❑Bentonite(20%solids) 0 Other Grout Placement Method APumped 0 Free Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed By Driller ❑Pump Contractor ❑ Other Concrete Pedestal ODimensions:Width_ ft Length Q ft Thick in 0 Christy Box ❑Stove Pipe PUMP Submersible❑Turbine ❑Other HP Pump Set tt Standing Water Level I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. i;{' 6t'IJ t11 l 3 AOUJR ADVANCE NOTICE Rfm0,�-61RFD FOR INSPECI TOMS-PLEAST CAU-(2)9)953-769-(, SIGNED C: A. TITLE._ �l `C e 1 1 <"� DATE ------------- S a DEPARTMENT USE ONLY Application Accepted By esar Ruvalcab Date 4/20/2020) Area 4/99 Employee ID# SK Grout Inspection By Date G G'7 L ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS PE SC Recelved Check#/ Amount Date Permit] Invoice# Well ID# Codes Info Cash Remitted Service Re uest M 4 /D 7 $145 4392 70 D 4366 180 420 WP0040737 4 #I t - 380 2 ZD WP 040738 EHD 43-06 6111201g WELL/PUMP PERMIT