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WELUPUMP PERMIT <br /> JAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)468-342D <br /> )N-REFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES'I YEAR FROM DATE ISSUED <br /> JOB ADDRESS /1J70E. Kettleman Ln clry/ZIPLodi, Ca 95240 Ln <br /> m <br /> m <br /> rr D <br /> CROSS STREET. T.vnn APN OS3)�Ll�a PARCEL SIZE a C✓ LAND USE APPLICATION# o <br /> OWNERNAME Lovina, Inc PHONE <br /> OWNERADDRESS P.O. Box 5379 CmISTATE/ZP Fresno,Ca 93755 <br /> ConrrrtAG-MM Purvianco DrillerBr INC PHONE209-887-3554 <br /> CONTRACTOR ADDRESS P.O. Box 64 CITYISTATE/ZIPLinden CA 95236 <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITYISTATEIZIP <br /> LICENSE X C-57 C-61 =:D-09 =Other NUMBER 377923 EXPIRATION DATE 7/31/21 <br /> BILLING PARTY; -:OWNER D CONTRACTOR G SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:G General Mineral/Coliform Bacteria(4391)D Dibromochloropropane(4392)D Arsenic(4393) <br /> INTENDED USE C DomestICIPrivate Ycfrrigation/Agricultural Industrial ❑Water Quality Monitoring Ti Soil Sampling/Characterization <br /> = Public Water System <br /> If different from Owner. Water System Name Contatt Name or Phone Number <br /> TYPE OF WORK New Well C Replacement Well Well Alteration/Modification P Other MF� <br /> Monitoring Well(s) #of wells Soil Boring(s) x of borings ❑Geotechnical #of borings E�V <br /> Out-Of-Service Well Out-Of-Service Well Renewal G Cross-Connection Repair i�O <br /> New Pump -Pump Replacement eump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method -Mud Rotary Air Rotary 7.Auger C Cable Tool C Push Point a Other Sq 7 2020 <br /> Proposed Well Depth ft Excavation in diameter D Open Bottom ❑Gravel Pack/Gravel Size <br /> Conductor Casing in diameter I Conductor Casing Depth ft E'4 LT//D ME/TA O NT?' <br /> Well Casing Diameter_In Thickness/Gauge/ASTM Sched C Steel C Plastic C Stainless Steel -Other 4(�TM L <br /> Grout Seal Depth ft Neat Cement(94 Ib bag/5-10 gal water) D Sand Cement sack mix/7 gal water ENT <br /> _'Bentonite(20%solids) 7 Other <br /> Grout Placement Method C Pumped _Free Fall D Other C Retardant!Accelerator(name) <br /> PEDESTAL Installed By Driller C Pump Contractor C Other <br /> Concrete Pedestal^—Dimensions:Width ft Length ft Thick in D Christy Box D Stove Pipe <br /> Pu MP _,Submersible Turbine 0 Other HP q00 Pump Set.2'O ft Standing Water Level f{ <br /> I HEREBY CERTIFY THAT I AVE PIkEPARED 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 /> SIGN TITLE <br /> DATE <br /> TTTT <br /> I I <br /> -----It <br /> I <br /> I <br /> u <br /> i I <br /> I <br /> i <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date % ✓ � Area �hl /' ' Employee ID# <br /> Grout Inspection By Date D 'SPECIAL Weil Permit <br /> Pump Inspection By� i.5 „ ( y'. Date I J)I L= L' D WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Permit/ <br /> Codes Info Cash <br /> . Remitted Date S ce 5egpest# Invoice# Well ID# <br /> 1 <br /> END 43-05 6/112019 2-2-7 <br /> —r wE11/PUMP PERMIT <br />