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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 1337 E.Kettleman Lane CITYIZIP Lodi,CA 95240 m <br /> D <br /> CROSS STREET Pixey Parrkwayyo APNt04931075 PARCEL SIZE 1.5 aC LAND USE APPLICATION# z <br /> OWNER NAME F LA J Pic CS LPHONE i N <br /> OWNER ADDRESS I61 D � !V�• DIAy!S CIN/STATEILP L'3,4- 1 C!s-Jai { <br /> CONTRACTOR Neil O'Anderson and Associates PHONE (209)588-2219 <br /> CONTRACTOR ADDRESS 902 Industrial Way CITY/STATE/ZJP Lodi,CA 95240 <br /> SUBCONTRACTOR/CONSULTANT Same as above PHONE Same as above _ <br /> SUBCONTRACTOR/CONSULTANT ADDRESS Same as above CITY/STATE21P Same as above <br /> LICENSE x C-57 C-61 D-09 Other NUMBER #669004 EXPIRATION DATE 05/31/2021 <br /> BILLING PARTY: OWNER CONTRACTOR 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 Replacement Well C Well Alteration/Modification n Other <br /> Monitoring Well(s) #of wells Soil Boring(s) #of borings X Geotechnical 2 #of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement Pump Repair 0 Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary XI Auger Cable Tool Push Point Other <br /> Proposed Well Depth 25 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 p Steel Plastic i Stainless Steel --Other <br /> Grout Seal Depth 25 ft X Neat Cement(94 Ib bag/5-10 gal water) Sand Cement sack mix(7 gal water <br /> Bentonite(20%solids) Other O <br /> Grout Placement Method Pumped Y Free Fall Other Retardant/Accelerator name UG <br /> Installed By Driller Pump Contractor Other V ?Q711 <br /> Concrete Pedestal Dimensions:Width ft Length It Thick in Christy Box Stove Pipe AQO/N <br /> PUMP Submersible Turbine Other HP Pump Set It Standing Water Level A ROHMCOON <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN SEP FNTA n' <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS ARTMFNT <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED_ TITLE Staff Engineer DATE 8/28/2020 <br /> 1 <br /> 1 <br /> i; <br /> DEPARTMENT USE ONLY <br /> Application Accepted By lG� Date 3/ ((7ati Area L��11 Employee ID# DA <br /> Grout Inspection By A Date I I iS I W D SPECIAL Well Permit <br /> Pump Inspection By Date l( I WAIVER Received <br /> Sal Boring Inspecyon By Date Constructed Well Depth pft y <br /> COMMENTS 2 (�19-0 I ifn O W r. (}�e f`eLL C n,,idl I� I�(��d�� (r'•5 J r <br /> PE sC Received Check#/ Amount Date Permit] Invoice# Well ID# <br /> Codes Info ash .Remitted Service Re uest# <br /> EHD 4&O6 6/11/2019 /�� ..-� WELL/PUMP PERMIT <br />