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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.S ov.or /ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 2459 Ma •gio Circle CITY/ZIP Lodi, CA 95240 <br /> <br />06241007 -4_4 CROSS STREET Stockton St <br />, APN ORM nn6 PARCEL SLITriergb.‘t --LAND USE APPUCATION # <br />OWNER NAME RtS iaEf I 4. 1 , . Co r 01 fr.) P. e yrivid Fe.,, LLe- . PH. , Y1') <br />OWNER ADDRESS .? 1-7... jokal S t CITY/STATE/ZIP tad I q (14 0 <br />Neil 0' Anderson arid Associates CONTRACTOR PHONE (209) 588-2219 <br />902 Industrial Way CONTRACTOR ADDRESS CITY/STATE/ZIP Lodi, CA 95240 <br /> <br />Same as above suscoNTRAcToRicoNsucrANT PHONE Same as above <br />SUBCONTRACTOR/CONSULTANT ADDRESS Same as above crryisrATEizip Same as above <br /> <br />LICENSE C-57 C-61 D-09 [ Other NUMBER #669004 EXPIRATION DATE 05/31/2021 <br />BILLING PARTY: OWNER X CONTRACTOR A SUBCONTRACTOR/CONSULTANT <br />ft Thick <br />PEDESTAL <br />. Christy Box u Stove Pipe <br />Installed By Driller Pump Contractor Other J Concrete Pedestal LiDimensions: Width ft Length <br />PUMP HP Pump Set ft Standing Water Level ft Submersiblel Turbine Other <br />06'361'41 <br />Pump Inspection By <br />Soil Boring Irjpigtion By <br />COMMENTS .-f" S Y1C <br />ea. <br />+Ma 11.1'17 <br />'( <br />a :. <br />11 <br />CPU <br />PAYMENT <br />RECEIVED <br />2 8 2021 <br />AN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />DEPARTMENT USE /ONLY <br /> <br />Application Accepted By t- 4- Date Lib SA2 / <br /> <br />Grout Inspection By Date <br />Date <br />Date 5-/•219a2-J <br />&gi 41ta w,j,1lC pipf <br />AreaLi 01,11tOd I Employee ID# <br />1 SPECIAL Well Permit <br />1 WAIVER Received <br />Constructed Well Depth <br />U? <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 INSPECT IONS - PLEASE CALL (209) 953-7697 <br /> TITLE Staff Engineer DATE 4/28/21 SIGNED _.%/4/ <br />DOMESTIC WELL SAMPUNG: 0 General Mineral/Coliform Bacteria (4391) 0 Dibromochloropropane (4392) o Arsenic (4393) <br />INTENDED USE Domestic/Private I Irrigation/Agricultural Industrial i Water Quality Monitoring X Soil Sampling/Characterization <br />Public Water System <br />If dKferent horn Owner: Water System Name Contact Name or Phone Number <br />DZESENSIBK 7 New Well Li Replacement Well C Well Alteration/Modification il Other <br />0 Monitoring Well(s) # of wells E Soil Boring(s) * of l'rings K Geotechnical 10 <br />0 Out-Of-Service Well C Out-Of-Service Well Renewal LI Cross-Connection Repair <br />il New Pump i Pump Replacement Li Pump Repair fl Raise Well Casing WELL CONSTRUCTION <br />i Drilling Method i Mud Rotary Air Rotary X Auger 1 Cable Tool ' Push Point ri Other <br />Proposed Well Depth 20 ft Excavation 6 1/4" in diameter L. Open Bottom H Gravel Pack/Gravel Size in diameter <br />7 Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched 1 1 Steel Plastic 1 Stainless Steel i Other <br />Grout Seal Depth 20 ft X Neat Cement (94 lb bag/5-10 gal water) Sand Cement sack mix/7 gal water <br />HBentonite (20% solids) -1 Other <br />Grout Placement Method E Pumped )1( Free Fall 0 Other <br />PE <br />Codes <br />SC <br />info <br />Received Vbflagjf Cash <br />Amount <br />Remitted Da .1 <br />Permit/ <br />in) <br />.3) Invoice # Well ID# <br />I-137d M--7 12-tiso$140%.11eRq j5 -0 Thril;,1 <br />s(3zdmtt) <br />C ot borings <br />Retardant / Accelerator (name) <br />EHD 43-06 6/11/2019 WELL /PUMP PERMIT