Laserfiche WebLink
WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)4683420 <br /> NON-REFUNDABLE PERMIT www.sigov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 10055 Rt Hwy 12 crrYlLP Lodi,CA 95240 <br /> re <br /> CROSS STREET K t0 l l Rd APN 0 51 1 2 0 6 0 PARCEL SIZE _ LAND USE APPLICATION# p <br /> OWNERNAME Glrolaml Farms — 6�2;k',.j / �ryt'yfD;31r1 PHONE H <br /> OWNER ADDRESS 1 1 5(12 r Fight Mile Rd CrTYISTATEMP Rtnr-kt-oR,.CA 95212 <br /> CONTRACTOR Furviance Drillers, INC PHoNr209-887_3554 <br /> CONTRACTOR ADDRESS P-0. BOX 64 CITY/STATEOPLinden CA 95236 <br /> SUBCONTRACTORICONSULTANT PHONE <br /> SUBCONTRACTORICONSULTANT ADDRESS CITYISTATEMP <br /> LICENSE X C-57 C-61 D-09 r'Other NUMBER 377923 EXPIRATION DATE 7/3 1/2 1 <br /> BILLING PARTY: _.OWNER 1-1 CONTRACTOR J SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPUNG:G General Mineral/Coliform Bacteria(4391),-1 Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE DomesticlPrivate Vingation/Agricultural Industrial ^Water Quality Monitoring G Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner. Water System Name Contact Nerve or Phone Number <br /> TYPE OF WORK :;New Well n Replacement Well ❑Well AlterationtModification ❑Other <br /> Monitoring Wells) #of wells L Soil Boring(s) of borings D Geotechnical #of borinp <br /> Out-Of-Service Well Out-OfService Wet]Renewal ❑Cross-Connection Repair <br /> New Pum �Pump Replacement --1 Pum Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method -.Mud Rotary il Air Rotary C Auger Cable Tool Push Point -: Other <br /> Proposed Well Depth ft Excavation in diameter ;7 Open Bottom 'I Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched Steel 7 Plastic 'l Stainless Steel :I Other <br /> Grout Seal Depth It ❑Neal Cement(94 Ib bag/S10 ga/water) Sand Cement sack mix/7 gal water <br /> C Bentonite(20%solids) U Other <br /> Grout Placement Method Pumped Free Fall r'.Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By .7 Driller ,Pump Contractor Other <br /> Concrete Pedestal i 1Dimenslons:Width ft Length It Thick in �j Christy Box Stove Pipe <br /> PUMP KSuhmers]bleCi TurbidA a Other HP Pump Set l t,-,Q ft Standing Water I e el <br /> I <br /> lt <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 /> r0 ti:,-i!?- <br /> SIGNED / TITLE `C/Lt -7t LI C DATE <br /> I <br /> 17 <br /> C <br /> CMENT <br /> ElV <br /> F <br /> O <br /> I <br /> 9 ?020 <br /> Nai U <br /> N <br /> pq � UNTY <br /> r <br /> t <br /> f DEPARTMENT USE NLY <br /> Application Accepted By ( Date dQ Z0 Area Employee ID# <br /> Grout Inspection By Date a f' _7 SPECIAL Well Permit <br /> Pump Inspection By �IcL N'.SL4�4";^l mac, Date I 1 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permitl <br /> Codes Info Cash Remitted Se i e Re neat# Invoice# Well ID# <br /> y3Y,l Qyl7 1 H (�LL. <br /> EHO 0.106 6/11f2019 WELL/Pl1MP PERMIT <br />