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755 WELL/PUMP PERMIT" SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205-6232 - (209)468-3420 NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR iN PECT:, EXPIRES 1 YEAR FROM DATE ISSUED LA JoBADDRESS rr 1"000 /V• -Arje1F•br„,,d Ave CITY/ZIP 95220 , ,� D CROSS STREET�lyL ed6r6ds;e Rd. APN 017-34-019 PARCEL SIZE 29.84 LAND USE APPLICATION F- I c) OWNER NAME Jeff Perlegos PHONE(209)712-2732 OWNER ADDRESS 15506 N. Curry Rd. CITY/STATE/ZIP Lodi, CA 95240 CONTRACTOR Delta Yufulp Tr1C PHONE ( 2oU 466-9625 CONTRACTOR ADDRESS 646 S. California St CITY/STATE/ZIP Stockton, CA 95203 SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE .- C-57 ,.XC-61 .. D-09 Other NUMBER 10 5 5 4 3 4 EXPIRATION DATE 8/16/2 0 GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE ❑ Domestic/Private X Irrigation/Agricultural -- Industrial L! Water Quality Monitoring ❑ Soil Sampling/Characterization ❑ Public Water System If different from Ovmer. Water System Name uontact Name or Phone Nurnuer TYPE OF WORK ❑ New Well ❑ Replacement Well Well Alteration/Modification ❑ Other :1Monitoring Wells) ,:of',velis Soil Boring #of borings Boring(s) L Geotechnical—��-�jr /�� -, Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair �- �” GWENT New Pum Pum Replacement Pum Reoair ❑ Raise Well CasingG' WELL CONSTRUCTION Drilling Method ❑ Mud Rotary ❑Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point L: Other Aft ' 2144-- Proposed Well Depth ft Excavation in diameter ❑ Open Bottom D Gravel Packer el Size in ciamoter ❑ Conductor Casing in diameter / Conductor Casing Depth ft JAENJOR�VIN COUNTY Well Casing Diameter_ in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainleskj>;&TH-CqN ;= Grout Seal Depth ft ❑ Neat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement sack rnix r dal water 0 Bentonite(20%solids) ❑ Other Grout Placement Method ❑ Pumped ❑ Free Fall C Other I Retardant/Accelerator(name) PEDESTAL Installed By ❑ Driller 'i Pump Contractor L Other Concrete Pedestal Dimensions:Width fL Length It Thick in Christy Box I Stove Pipe PUMP Submersible Turbine Other HP 25 Pump Set 1100 ft Standing Water Level 85 ft [ 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. I 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 COMIRENU.TJON LAWS. •� �n 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS SIGNED / TrrLE CEO DATE 7/6/2020 i I i ��IQ�fl' .�Illllllls� .W A' •I rA - r i� t+ I DEPARTMENT USE ONLY Application Accepted By Date 7 /3 J;O Area 4 Employee ID,/ DA_ Grout Inspection By Date SPECIAL Well Permit Pump Inspection By Gran,wSU Z to v�, Date I F—Itinu WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS PE SC Received Chec Amount Date Permit/ Invoice# Well ID# Codes Info B a Remitted Service Request# 'i381 0�o 1.1), 1-D Wpo EHD 43-0u 8/04/08 WELL/PUMP PERMIT