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JOB ADDRESS 20340 St Rt 99 Frontage Rd. CITY/ZiP 95220 <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPAPriviENT 1868 EAST HAzELToN AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />NON-REFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />CROSS STREET Acampo Rd APN 017-31-015 PARCEL SIZE 14 33 LAND USE APPLICATION # <br />OWNER NAME Jeff Perlegos <br />PHONE 209-663-9026 <br />CONTRACTOR ADDRESS ID Ineeltkiviiirk Orly <br />CONTRACTOR e l I Po 1v1 p <br />OWNER ADDRESS 15506 N Curry Ave <br />CITY/STATE/Zip <br />CITY/STATE/ZIP Lodi CA 95240 <br />PHoNE °C) (Aq .7/c?-1 <br />SUBCONTRACTOR/CONSULTANT <br />PHONE <br />SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP <br />LICENSE - C-57 IX C-61 El D-09 1 Other <br />BILLING PARTY: 7 OWNER - CONTRACTOR C SuBcoNTRAcToRJCoNsuLTANT <br />NUMBER 1055434 EXPIRATION DATE 7/31;2021 :SS3LICICIV 311S INTENDED USE <br />Proposed Well Depth ft Excavation in diameter 1 Open Bottom r Gravel Pack/Gravel Size in diarngY <br />WELL CONSTRUCTION <br />Drilling Method 1 Mud Rotary Air Rotary - Auger C Cable Tool - Push Point r Other 1 H DEP,464.74L <br />TYPE OF WORK I New Well 1 Replacement Well I Well AfterationiModification Other <br />fell/IV*r. <br />Well Casing Diameter in ThicknessiGauge,ASTM Schecl .J Steel _ Plastic _ Stainless Steel _J Other Grout Seal Depth ft I Neat Cement (94/b bag/5-10 gal water) Sand Cement sack mix,7 gal water L Bentonite (20% solids) L Other <br />Conductor Casing in diameter i Conductor Casing Depth ft <br />Out-Of-Service Well I Out-Of-Service Well Renewal <br />goon g.:<, <br />New Pump _ Pump Replacement X Pump Repair <br />Monitoring Wall(s) # of wells L Soil Boring(s) ii 71 t7.-,1-Kri, eo <br />Water System Name <br />_ Raise Well Casing <br />SAN Jo i 0 2020 <br />Geotechnical <br />Cross-Connection Repair <br />Contact Name or Phone Number <br />_i <br />i iEA L , ...N44 -U/v 1-4 Ail///(-9tjiN Cn <br />Grout Placement Method Pumped Free Fall I Other I Retardant! Accelerator (name) <br />PEDESTAL Installed By 7 Driller C Pump Contractor 1 Other <br />L Concrete Pedestal _Dimensions V\Adth ft Length ft Thick in _ Christy Box j Stove Pipe <br />Pr Submersible 1 Turbine i - Other HP 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 />8 HpUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED AZ__ Trns CEO DATE 10/22/2020 <br />I I I <br />DEPARTMENT USE ONLY <br />DOMESTIC WELL SAMPLING: I General Mineral/Conform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />Domestic/Private X Irrigation/Agricultural _ Industrial _ Water Quality Monitoring L sod Sampling/Characterization I Public Water System <br />I! different from Owner <br />[Pump <br />Application Accepted By Z2 <br />Grout <br />- <br />Grout Inspection By <br />Pump Inspection By tiVoN LI} L6 bev.t.:4', Date (-1141;1" <br />Soil Boring Inspection By <br />COMMENTS <br />Date <br />Date <br />Date <br />Area Employee ID# <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth <br />PE <br />Codes <br />SC <br />Into <br />Received <br />0.1, o <br />Check#I ...astr"- Amount <br />Remitted Date Permit/ <br />Service Request # Invoice # Well IDft <br />___, '13 K.2 10 ,01.h v‘iNglyi 4) <br />FHD 43-06 6111r2019 : !Pt P:1T