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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 www.sjgov.org/ehd EXPIRES 'I YEAR FROM DATE ISSUED <br /> JOB ADDRESS 8000 E Kettleman Lane cITY/zIP Lodi 95240 N <br /> I m <br /> CROSS STREET /^`LP-N L �C� 0 61 -1 3 3-3 8 C. D <br /> APN PARCEL SIZE 'LAND USE APPLICATION# o <br /> z <br /> OWNERNAM'c Joh & Varene A Teresi Family LP PHONE vi <br /> OWNER ADDRESS PO BOX 819 CITYISTATE/ZIP Lodi , CA 95241 <br /> CONTRACTOR Purviance Drillers , INC PHONE209-887-3554 <br /> CONTRACTOR ADDRESS P.O. BOX 64 CITY/STATE/ZIPL i nd en CA 95236 <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITYISTATE/ZIP <br /> LICENSE X C-57 C-61 D-09 ❑ Other NUMBER 377923 EXPIRATION DATE 7/31 /21 <br /> BILLING PARTY: OWNER ❑CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: ; General Mineral/Coliform Bacteria (4391)U Dibromochloropropane(4392)I_ Arsenic(4393) <br /> INTENDED USE Domestic/Private )( Irrigation/Agricultural Industrial ❑ Water Quality Monitoring Soil Sampling/Characterization <br /> _ Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK XNew Well Replacement Well Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells Soil Boring(s) #of borings Geotechnical #of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method X"MUd Rotary Air Rotary Auger Cable Toot Push Point Other <br /> Proposed Well Depth S5-0 ft Excavation 14 12- in diameter X Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing NIR' in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter 12Ain Thickness/Gauge/ASTM Sched .2't/ X Steel Plastic Stainless Steel ! Other <br /> Grout Seal Depth ft Neat Cement(94 Ib bag/5-10 gat water) )t Sand Cement 10-3 sack mix/7 gal water <br /> _ Bentonite(20%solids) Other <br /> Grout Placement Method Y Pumped Free Fall i Other Retardant/Accelerator(name) <br /> (PEDESTAL Installed By )4 Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width ft Length ft Thick in Christy Box Stove Pip.— <br /> au-_MP <br /> ipePUMP Submersible Turbine Other HE Pump Set ft Standing Water Level ft <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 /> ')TICE REQUIP' ? FO INSPECTIOW" "LEASE CALL 3-769: <br /> SIGNED \ C C Lel ` L C d Iic �r TITLE DATE 946-20 <br /> E M <br /> } <br /> W I <br /> o , <br /> IVED <br /> L <br /> DEPARTMENT USE ONLY HE4LTH[)coA.0.TnAPNT <br /> Application Accepted By Date Area L4 G Employee ID# <br /> Grout Inspection By Date Q I SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth Foc) ft <br /> COMMENTS GrOvl G Qc� Q a LP 3 S <br /> PE SC Received Check#/ Amount dt Permit/ Invoice# Well ID# <br /> Codes I Info A Cash Remitted Service Request# <br /> EHD 43-06 6/-112019 <br /> WELL/PUMP PERMIT <br />