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t <br />c <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 14300 Devries Rd <br />CITY/ZIP <br />Lodi/95242 <br />CROSS STREET Kingdon Rd APN 055-240-050 <br />PARCEL SIZE 20.36 acresLAND USE APPLICATION # <br />DWNER NAME True & Susan Lambie <br />PHONE 209-327-2262 <br />DWNER ADDRESS 14300 Devries Rd <br />CITY/STATEMP <br />Lodi. CA 95242 <br />CONTRACTOR West Coast Exploration Inc <br />PHONE 209-985-7541 <br />CONTRACTOR ADDRESS P.O. Box 133 <br />CITYISTATEIZIP <br />Escalon/CAI95320 <br />SUBCONTRACTOR/CONSULTANT CTE Cal Inc <br />PHONE 209-543-1799 <br />SUBCONTRACTORICONSULTANT ADDRESS 4230 KiPman Ave StP 150 <br />CITY/STATE/ZIP <br />Modesto/CA/95356 <br />LICENSE x C-57 C-61 609 Other <br />NUMBER 870761 <br />EXPIRATION DATE 1/31/2022 <br />BILLING PARTY: OWNER CONTRACTOR <br />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 Soil 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 Soil Borings) # of borings x Geotechnical 2 # 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 x Auger Cable Tool Push Point Other <br />Proposed Well Depth 20 It Excavation 4 inches in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth It <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br />Grout Seal Depth It x Neat Cement (94 lb bag15-10 gal water) Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method Pumped x Free Fall Other 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 It Standing Water Level ft <br />I HEREBY CERTIFY THAT 1 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. 1 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 />MI�8 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED / TITLE Staff Engineer DATE 7/7/2021 <br />ti <br />m <br />D <br />0 <br />N <br />N <br />>� ,✓DEPARTMENT USE ONLY q� A <br />Application Accepted By i- 1'���`�— Date 7 Area Employee ID# <br />Grout Inspection By Date SPECIAL Well Permit <br />Pump Inspection By � Date WAIVER Received <br />Soil Boring Inspection By 4/�ice" Dat 7 -"-?121 Constructed Well Depth ft <br />COMMENTS -TFGf0V JP V4G1 'fir tv&-Oun _C�Ywl%. 41-e tlwl p ,Djnv 3,. bP 1jee-y-, <br />EHD 43-06 6111/2019 6 W. <br />--f 12S D 7 <br />35- WELL /PUMP PERMIT <br />�Amount Permiv r. <br /><�M�ANUH.Wr r��l►�rr A00� <br />EHD 43-06 6111/2019 6 W. <br />--f 12S D 7 <br />35- WELL /PUMP PERMIT <br />