Laserfiche WebLink
WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AvENUE-STOCKTON CA 95205-6232(209)4683420 <br /> NON-REFUNDABLE PERMIT www.sjgov.org/ohd EXPIRES 1 YEAR FROM DATE ISSUED <br /> E Harney Lane /n <br /> Joe ADDRESS 0 Y CmZP Lodi,CA 95240 (y <br /> CROSS STREET S Stockton Street ApN 058-130-250 PARCELSIZE 1 O.3 aC LAND USE APPLICATION# o <br /> OWNER NAME Diane Tsutsumi/Gary Tsutsumi PHONE n <br /> OWNER ADDRESS 1607 Trona Way CmISTATE/LP San Jose, CA 95125 <br /> CONTRACTOR West Coast Exploration, Inc. PHONE (209)985-7541 <br /> CONTRACTOR ADDRESS P.O.Box 133 Cm/STATE/LP Escalon,CA 95320 <br /> SUBCONTRACTOR/CONSULTANT Stevens, Ferrone&Bailey Engineering Company, Inc. PHONE (925)688-1001 <br /> SUBCONTRACTOR/CONSULTANTADDRESS 1600 Willow Pass Court Cm/STATEMI,Concord,CA 94520 <br /> LICENSE ,,C-57 C-61 n D-09 n Other NUMBER 870761 ExPIRATION DATE 01/31/2022 <br /> BILLING PARTY: 1 OWNER F1 CONTRACTOR X SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391)n Dibromochloropropane(4392)r Arsenic(4393) <br /> INTENDED USE Domestic[Private -Irrigation/Agricultural Industrial n Water Quality Monitoring )(Soil Sam piing/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 n Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells X Soil Boring(s) 4 #of borings Geotechnical #of borings <br /> Out-Of-Service Well n Out-Of-Service Well Renewal !Cross-Connection Repair <br /> F!New Pump n Pump Replacement n Pump Repair n Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method n Mud Rotary n Air Rotary X Auger r 1 Cable Tool n Push Point n Other <br /> Proposed Well Depth 10-20 It Excavation 5 in diameter n Open Bottom ft Gravel Pack/Gravel Size in diameter <br /> n Conductor Casing N/A in diameter / Conductor Casing Depth N/A ft <br /> Well Casing Diameter,NLA in Thickness/Gauge/ASTM Schad n Steel n Plastic 1 1,Stainless Steel i Other <br /> Grout Seal Depth 10-20 It X Neat Cement(94 Ib bagi/5-10 gal water) n Sand Cement sack mixr7 gal water <br /> Bentonite(20%solids) n Other <br /> Grout Placement Method Pumped X Free Fall X Other is encountered n Retardant/Accelerator(name) <br /> PEDESTAL !rA Installed By Driller n Pump Contractor n Other <br /> ._Concrete Pedestal 1Dlmenslons:Width ft Length It Thick in n Christy Box F Stove Pipe <br /> PUMP 1/P1 -Submersible-Turbine 'r Other HP Pump Set It 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 /> MINIIIIIUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED . TRLE Owner/Operator DATE 06/15/2021 <br /> RF YMF <br /> q o N23?0 <br /> n q /"0 M�cod?� <br /> R �N�y <br /> DEPARTMENT USE NLY <br /> Application Accepted By �r �� Date va Area / s✓ Employee ID# <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date p I WAIVER Received <br /> Soil Boring Inspection By Date 2 D Z k Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received Chec Amount ate Permit/ Invoice# Well ID# <br /> Cods Info ,Remitted Service Re u s # <br /> EHD11-06 6/112019 WELL/PUMP PERMIT <br />