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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 wW W.s Ov.or 1ehd EXPIRES 7 YEAR FROM DATE ISSUED <br /> eSrAwani Dr Lodi,CA 95240 m <br /> JOB ADDRESS �O.fCI7Y,-,,.. <br /> /� D <br /> CROSS STREET Mokelumne River Dr APN A 4 101/'yam (�V?/f PARCEL SIZE-?-AND USE APPLICATION# a <br /> OWNER NAME Union Pacific Railroad PHONE(402)544-2452 >A <br /> OWNER ADDRESS 1400 Douglas St,Omaha,NE 68179 CnYISTATmP <br /> CONTRACTOR <br /> Taber Drilling PHONE 916-837-5883 <br /> 536 Galveston St,West Sacramento,CA 95691 <br /> CONTRACTOR ADDRESS CfrYISTATE21P ^ p <br /> SUBCONTRACTORICONSULTANT Shannon tot Wilson PHONE 217-821-4807 <br /> SUBCONTRACTORICONSULTANT ADORES5664 W Broadway,Glendale,CA 91204 C ISTATHMP <br /> LICENSE X C-57 - C-61 ID-09 _Other NUMBER 969927 EXPIRATION DATE 2/28/2022 <br /> BILLING PARTY: OWNER CONTRACTOR X_SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING:_I General Mineral/Coliform Bacteria(4391)L Dibromochloropropane(4392)L Arsenic(4393) <br /> INTENDED USE _Domestic/Private ❑Irrigation/Agricultural n Industrial -Water Quality Monitoring X Soil Sampling/Characterization <br /> Public Water System <br /> If different from Ower Welar System Name C.WU Name n<Phone Number <br /> TYPE OF WORK r New Well -Replacement Well Well Alteration/Modification C Other <br /> Monitoring Wells) ;V of wells r Soil Boring(s) Aof bonn9s X'Geotechnical 2 Sof body <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump I Pump Replacement - Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary Auger I Cable Tool r-Push Point 1 Other <br /> Proposed Well Depth 120 it Excavation in diameter :Open Bottom C Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth k <br /> Well Casing Diameter In Thickness/GaugelASTM Schad Steel Plastic Stainless Steel Other <br /> Grout Seal Depth.1 2U R t yNeat Cement(94 Ib bag3-10 gal Hater) -Sand Cement sack mixO gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method ]Pumped 7 Free Fall �-Other I remle L Retardant I Accelerator(name) <br /> PEDESTAL Installed By -.Driller C Pump Contractor Other <br /> L Concrete Pedestal!Dimensions:Width_R Length R Thick in L Christy Box ,Stove Pipe <br /> PUMP C Submersible-Turbine D Other HP Pump Set ft Standing Water Level it <br /> IN <br /> 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 /> ff �UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE Executive Vice President DATE 10'06'2020 <br /> RFgyM <br /> o �Fi�tin <br /> sqN✓ �T�3 FO <br /> h'Fq�TyR zN co X70 <br /> OF iq <NTy <br /> ILI -FT-FT-T- <br /> MFN� <br /> DEPARTMENT USE ONLY LI <br /> Application Accepted By .e9::::f L/� Data 1013 0J10 Area 1 L'3�� Employee ID#jr)�& <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By h Data k Constructed Well Depth tt <br /> COMMENTS `f Of SM o Al ( j:LV <br /> PE SC Received Check#/ Amount to Permit! Invoice# Well ID# <br /> Codes Info Cash Remitted I Servicea st# <br /> Utz F0F <br /> EHD43-0 N IM19 WELL(PUMP PERMIT <br />