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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.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 1679 Lower Sacramento Road CITy/ZIP Lodi/95242 <br />CROSS STREET Sunwest Plaza APN 058-030-29 PARCEL SIZE 2'43 ac LAND USE APPLICATION # <br />OWNER NAME Browman Development Company PHONE (925) 588-2219 <br />OWNER ADDRESS 1556 Parkside Drive CITY/STATE/ZIP Walnut Creek/CA/94596 <br />CONTRACTOR Salem Engineering Group, Inc. PHONE (559) 271-9700 <br />CONTRACTOR ADDRESS 4729 W. Jacquelyn Avenue CITY/STATEIZIP Fresno/CA/93722 <br />SUBCONTRACTOR/CONSULTANT Salem Engineering Group, Inc. PHONE (559) 271-9700 <br />SU13CONTRACTORICONSULTAW ADDRESS 4729 W Jacquelyn Avenue cmr/STATE21P Fresno/CA/93722 <br />LICENSE JC -57 C-61 D-09 Other NUMBER 970772 ExPIRATION DATE March 31, 2022 <br />BILLING PARTY: OWNER 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 lv^oil 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 Alteration/Modification Other <br />Monitoring Well(s) # of wells JSoil Boring(s) four # of Ings Geotechnical # 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 JAuger Cable Tool Push Point Other <br />Proposed Well Depth 5 to 50 ft Excavation 6 in diameter Open Bottom 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 Plastic Stainless Steel Other <br />Grout Seal Depth 5 to 50 it Neat Cement (941b bag15-10 gal water) Sand Cement sack mixl7 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method Pumped ree Fall Other tremmie Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor Other <br />Concrete Pedestal Dimensions: Width ft Length ft Thick in Christy Box Stove Pipe <br />PUMP Submersible Turbine 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 />MINIMUM HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED TITLE Geotechnical Staff Engineer DATE June 23, 2021 <br />DEPARTMENT USE ONLY <br />Application Accepted By Date r - ay l <br />Grout Inspection By Date <br />Pump Inspection By Date <br />Soil Boring Inspection By Data <br />COMMENTS 'r--aroor1[ WeA 'e1' IS ereouyitvrea or 6orin4 <br />Area LO6I1 EmployeeID#NA <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well <br />ft <br />C'�i�- I�►1!:,J■I��F�IF.7(r:�1t�J.�1JLily�Li►'�� <br />EHD 43-06 6/1112019 / • i(1. L' � )��� � ���_ <br />WELL /PUMP PERMIT <br />EHD 43-06 6/1112019 / • i(1. L' � )��� � ���_ <br />WELL /PUMP PERMIT <br />