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PAYMENT <br />RECE WED <br />APR 2 8 2021 <br />—SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />EALTH DEPARTMENT <br />Area 'IA Cl Employee Oft DA <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Ir2pection By <br />COMMENTS —L er- < cmc,611 1.3-1 ocki.N> slc.-+L/Cr....53 • <br />SPECIAL Well Permit <br />Date <br />Date ‘1\t (-1.1 Constructed Well Depth ft <br />elioa feil^n1 p 12t. be <br />WAIVER Received <br />t, . <br />DEPARTMENT USE, ONLY <br />Date R/42 Application Accepted By 2— Li— <br />WELLJPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE- STOCKTON CA 95205 -6232 (209)468-3420 <br />NON-REFUNDABLE PERMIT www.sislov.orgiehd EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 9150 CA-12 _ST RT 1a crivzip Lodi, CA 95240 <br />CROSS STREET <br /> <br />Buella Rd APN 05112048 PARCEL SIZE 2.0 ac. LAND USE APPLICATION # <br />OWNER NAME kNel I v 3 _i_felne 11/ PHONE <br />OWNER ADDRESS 153' 31 c of (;)1e.) Re.; iet 12. d CITY/STATE/ZIP sw is — <br />Neil 0' Anderson and Associates CONTRACTOR PHONE (209) 588-2219 <br />CONTRACTOR ADDRESS 902 Industrial Way <br />CITY/STATE/ZIP Lodi, CA 95240 <br />SUBCONTRACTOFt/CONSU Same as aboveLTANT PHONE Same as above <br />SUBCONTRACTOR/CONSULTANT ADDRESS Same as above <br />CITY/STATE/ZIP Same as above <br />LICENSE C-57 C-61 D-09 Other NUMBER #669004 EXPIRATION DATE 05/31/2021 <br />BILLING PARTY: OWNER )( CONTRACTOR SUBCONTRACTOFt/CONSULTANT <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE Domestic/Private I Irrigation/Agricultural I Industrial Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System <br />If different from Owner: <br />TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br />Monitoring Well(s) # of wells Soil Boring(s) ft or bonn9a K Geotechnical 2 <br />Out-Of-Service Well Out-Of-Service Well Renewal ' ' Cross-Connection Repair <br />1 New Pump , Pump Replacement 1 Pump Repair i I Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method Mud Rotary Air Rotary X Auger Cable Tool Push Point Other <br />Proposed Well Depth 20 ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched , Steel Plastic Stainless Steel Other <br />Grout Seal Depth 20 ft X. Neat Cement (94 lb bag/5-10 gal water) 1 Sand Cement sack mix/7 gal water I Bentonite (20% solids) Other <br />Grout Placement Method _ Pumped )(( Free Fall <br />PEDESTAL Installed By Driller Pump Contractor Other <br />Concrete Pedestal Dimensions: Width ft Length <br /> <br />ft Thick Christy Box J Stove Pipe <br /> <br />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 />MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />TITLE Staff Engineer DATE 4-28-2021 <br />PE <br />Codes <br />SC Received <br />Info 4psount Date Pe mit/ <br />Servic Well ID#itted Invoice # <br />-)37 <br />All sas on, <br />ik <br /> K <br />, <br />ip <br />1429 /(A <br />bt# <br />WELL /PUMP PERMIT <br />Water System Name Contact Name or Phone Number <br />*of borings <br />Other Retardant / Accelerator (name) <br />in diameter <br />PUMP I Submersible Turbine Other HP Pump Set ft Standing Water Level <br />SIGNED :SS3/10aV 311S