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WELLIPUMP PERMIT SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)468-3420 NON-REFUNDABLE PERMIT WwW.S Ov.or /ehd EXPIRES 1 YEAR FROM DATE ISSUED JOBADDRESS 9363 W. Hwy 12 CiTy/ZAP Lodi,CA 95240 m Terminous7 a CROSS STREET _ APN 0511 2009 PARCEL SIZE 0-1!LAND USE APPLICATION# p owNERNAME Knoll Farms 1/pflmar- pKyw(l PHONE OWNER ADDRESS 93 6 3. 731 CIN/STATE/ZIP CONTRACTOR Furvi ante Drillers, INC PHoNE209-887-3554 coNTRACTDRADDRESsP-O. Box 64 CITY/STATErzIPLinden CA 95236 SUBCONTRACTORICONSULTANT PHONE SUBCONTRACToR/CONSULTANT ADDRESS CITY/STATE21P LICENSE Rr C-57 D C-6f 0 D-09 0 Other NUMBER 377923 EXPIRATION DATE 7/31/21 BILLING PARTY: D OWNER D CONTRACTOR D SUBCONTRACTORICONSULTANT DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)0 Dibromochioropropane(4392)D Arsenic(4393) INTENDED USE D Domestic/Private )(Irdgation/Agriculturai D Industrial D Water Quality Monitoring 0 Soil Sampling/Characterization C Public Water System Ifdifferentfom Owner. Water System Name Contact Name or Phone Number TYPE OF WORK C New Well ❑Replacement Well 0 Well AlterationlModification ❑Other ❑Monitoring Well(s) #of wells ❑Soil Bo6ng(s) #of borings ❑Geotechnical #of borings D Out-Of-Service Well ❑Out-Of-Service Well Renewal D Cross-Connection Repair ❑New Pump ❑Pump Replacement ifump Repair ❑Raise Well Casing WELL CONSTRUCTION --- Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑ Other Proposed Well Depth ft Excavation in diameter D Open Bottom D Gravel Pack/Gravel Size in diameter ❑Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter_In ThicknessfGauge/ASTM Schad D Steel ❑Plastic ❑Stainless Steel [i Other Grout Seal Depth ft D Neat Cement(941b bag/,-10 gal water) 0 Sand Cement sack m1x17 gal water ❑BentonRe(20%solids) 0 Other Grout Placement Method D Pumped D Free Fall ❑Other 0 Retardant/Accelerator(name) PEDESTAL Installed By Driller C Pump Contractor ❑ Other ❑Concrete.Pedestal❑Dimensions:Width it Length ft Thick in D Christy Box. ❑Stove Pipe PUMP ❑Submersible% Turbine ❑Other HP S Pump Set it Standing Water Levelft 1 HEREBY CERTIFY THAT 1 kAVE 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 COMPENSATION LAWS. IM. UM 4t3(�`°{,/SUR€�,L�vANC NOTICE RECUIRED FOR+N'SPErpTION'yS-PLEASE CALL(2q9) SIGNED (.C -c/^LlA._{ TrfLE UT-ClL(A DATE T E® 2020 O OUNTY VI N TAL MEW / 'DEPARTMENT USE ONLY C,r� Application Accepted By � Date /I /� d Area CjCf Employee ID# I x Grout Inspection By Date r!� Ll SPECIAL Well Permit Pump Inspection By e,�t+1 LQ"'y f L Date �`1 '/.�f 101D ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS PE SC Received Check#/ Amount Date Permit/ Codes Info B Cash Remifted is a Invoice# Well ID# -3 Ed EHO4346 6!1112019 WELL/PUMP PERMIT