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• T <br /> 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.or /g ehd _ EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 701 South Ham Lane 1 CITY/Z{IP Lodi <br /> CROSS STREET Wy\Tokay St o APN �ZZ�$y PARCEL SIZE /4 6 LAND USE APPLICATION# <br /> OWNER NAME //�I<<<t .51PfreA C&ne5�l�e-_& PHONE / y� CA <br /> OWNER ADDRESS C O S_ '�th J f 1,5"" ' CITY/STATEMP /r /l1.r..c W1,J& 1 1N 5_5q0.z <br /> CONTRACTOR Moore Twining and Associates Inc PHONE r_559-268-7021 <br /> CONTRACTOR ADDRESS 2527 Fresno Street CITY/STATE/ZIP Fresno,CA 93721 <br /> SUBCONTRACTOR/CONSULTANT TGR Geotechnical,Inc PHONE <br /> SUBCONTRACTOR/CONSULTANTADDRESS 3037 S Harbor CITY/STATE/ZIP Santa Ana,CA,92704 <br /> LICENSE XC-57 C-61 D-09 Other NUMBER 506159 EXPIRATION DATE02-28-2021 <br /> BILUNG PARTY: OWNER X CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) 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 New Well Replacement Well Well Alterabon/Modification Other <br /> Monitoring Well(s) #of Wells Soil Boring(s) #of borings XX Geotechnical 4 #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 Mud Rotary Air Rotary Auger Cable Tool Push Point X Other Hollow Stem <br /> Proposed Well Depth 2X251 2X1V Excavation 6" in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth It <br /> Well Casing Diameter_in Thidmess/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br /> Grout Seal Depth ft Neat Cement(94 Ib bagIS-10 gal water) XXSand Cement full backfill sack mixf7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped X Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width ft Length It Thick in Christy Box Stove Pipe <br /> PUMP Submersible Turbine Other HP Pump Set ft Standing Water Level It <br /> I HEREBY CERTIFY THAT 1 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 /> MINIMUM 48 OU CE CE REQ ED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TRLE Division Manager,PG DATE 01-05-2021 <br /> Ec MFNT <br /> FI V ED <br /> AR 1 j 2021 <br /> DAo U <br /> ' )N COUNry <br /> A Q p TAT <br /> DEPARTMENT USE ONLY <br /> Application Accepted By �L Date 3 �7 / Area LOL Employee ID# D� <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date77 WAIVER Received <br /> Soil Boring Inspection By e2g"_ Date) Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B ash Remitted ice Re u t <br /> 7 X50 Vt 1i b1VU041S <br /> EHD 43-06 6/11/2019 /�/ 4/�]D WELL/PUMP PERMIT <br />