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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 vvww.sjgov.orglehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOBADDREss 14'/250 N Devries Rd CrrrizrP Lodi 95242 <br /> CROSS STREET! _ D.S D <br /> ((II APN PARCEL SIZE��J LAND USE APPLICATION# p <br /> a <br /> OWNER NAME Woods Dairy m <br /> PHONE rn <br /> OWNER ADDRESS 14250 N Devries Rd CITT/STATE/ZIPLOdi,Ca (5242 <br /> CONTRACTOR Purviarice Drillers, INC PHONE209-887-3554 <br /> CONTRACTOR ADDRESS P-0- BOX 64 Crry/STATE/ZIPLi nden CA 95236 <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTORICONSULTANT ADDRESS CITY/STATE/ZIP <br /> LICENSE X C-57 ;C-61 . 0-09 ::Other NUMBER 377923 EXPIRATION DATE 7/3 1/2 1 <br /> BILLING PARTY: OWNER i;CONTRACTOR G SUBCONTRACTOR/CONSULTANT <br /> DOMEsnc WELL SAMPLING:C General Mineral/Coliform Bacteria(4391)Fl.Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE is Domesfic/Private Irrigation/Agricultural i.;Industrial Water Quality Monitoring i;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 I'Replacement Well ^Well Nteration/Modification Other I M�•, <br /> Monitoring Well(s) #of wells Sail Borings) °of bO"nys L;Geotechnical tt of bod gs ^/ ry T <br /> Out-Of-Service Well OUt-OfService Well Renewal Cross-Connection Repair c �D <br /> ii New Pump =Pump Replacement ?hump Repair Raise Well Casino <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary Auger CSble Tool Push Point 'i Other S 4 �O?O <br /> Proposed Well Depth ft Excavation in diameter Open Bottom ❑Gavel Pack/Gravel Size IwI <br /> Conductor Casing in diameter / Conductor Casing Depth ft —�qL- I, MECO( NTN <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched ;;Steel L Plastic 11 Stainless Steel -1 Other N O 'E 1.7 C <br /> Grout Seal Depth ft Neat Cement(94 lb bag/5-10 gal water) I]Sand Cement sack mix/7 gal water E/V] <br /> Bentonite(20%solids) �Other <br /> Grout Placement Method -: Pumped i Free Fall C Other _Retardant/Accelerator(name) <br /> PEDESTAL Installed By L Driller _Pump Contractor L- Other <br /> Concrete Pedestal.Dimensions:Width ft Length ft Thick in - <br /> Christy Box Stove Pipe <br /> PUMP ::Submersibl urbine :]Other HP Pump Set ft Standing Water Level_z/5 _g <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 /> 40VANGE NOTICE REQUIRED FOR.hlSPF:1033S-PLEASE CALL,(209)95)3-7697 <br /> SIGNED ..1.-I/i X LA4c'-=.0 <br /> � TITLE DATE <br /> er <br /> DEPARTMENT USE ONLY <br /> Application Accepted By_ _C-���y Date yl J '-' Area IF Employee ID# :{ <br /> Grout Inspection ByDate it SPECIAL Veil Permit <br /> Pump Inspection By 'v '• ti Date �Zil/11-`l�li i, WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check* Amount Permit/ <br /> Codes Info ash Remitted Date Service Re uest# Invoice# WellID# <br /> `i3 75 � t <br /> EHD 43-OB 6/112018 WELL/PUMP PERMR <br />