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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.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> N <br /> JOB ADDRESS 2825 S Stockton Street CITYZP Lodi,CA 95240 b�yyy <br /> CROSS STREET W Harney Lane APN 058-130-220 PARCEL SIzE 8.4 ac LAND USE APPLICATION# O <br /> p <br /> m <br /> OWNER NAME Grace and Giuseppe Puccinelli PHONE <br /> OWNER ADDRESS 2719 S Stockton St CrrY/STATEmp Lodi,CA 95240 <br /> CONTRACTOR West Coast Exploration, Inc PHONE (209)985-7541 <br /> CONTRACTOR ADDRESS P O Box 133 CrrY/STATEZP Escalon,CA 95320 <br /> SUBCONTRACTOR/CONSULTANT Stevens, Ferrone&Bailey Engineering Company, Inc PHONE (925)688-1001 <br /> SUBCONTRACTOR/CONSULTANTADDRESS 1600 Willow Pass Court CrrY/STATEMp Concord,CA 94520 <br /> LICENSE ,1`,C-57 C-61 r'.D-09 ri Other NUMBER 870761 EXPIRATION DATE 01/31/2022 <br /> BILLING PARTY: F OWNER n CONTRACTOR X SUBccN rRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:i General Mineral/Coliform Bacteria(4391)n Dibromochloropropane(4392)F1 Arsenic(4393) <br /> INTENDED USE "- Domestic/Private Irrigation/Agricultural r- Industrial n Water Quality Monitoring X 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 f Replacement Well n Well Alteration/Modification n Other <br /> Monitoring Wells) If of wells X Soil Bonng(s) ! #of borings F Geotechnical It of borings <br /> I i Out-Of-Service Well FI Out-Of-Service Well Renewal n Cross-Connection Repair <br /> I New Pum 1-1 Pump Replacement FI Pump Repair Fl Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method r1 Mud Rotary n Air Rotary X Auger f 1 Cable Tool ;Push Point n Other <br /> Proposed Well Depth 10-20 It Excavation 5 in diameter I i Open Bottom i I Gravel Pack/Gravel Size in diameter <br /> n Conductor Casing N/A in diameter / Conductor Casing Depth N/A R <br /> Well Casing Diameter NL&in Thickness/Gauge/ASTM Schad n Steel ❑Plastic n Stainless Steel I- Other <br /> Grout Seal Depth 10-20 it Xt,Neat Cement(941b bag/5-10 gal water) n Sand Cement sack mix7 gal water <br /> I Bentonite(20%solids) �]Other T,,—,-JLgmuadsrator <br /> Grout Placement Method n Pumped X Free Fall >C Other is encountered n Retardant/Accelerator(name) <br /> PEDESTALI�:/A, Installed By Driller F:'Pump Contractor FI Other <br /> Concrete Pedestal nDlmenslons:Width It Length ft Thick in FI Christy Box 1 Stove Pipe <br /> PUMP �NUA Submersible;'Turbine i'.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 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL(209)953-7697 <br /> SIGNED TITIF Owner/Operator DATE 06/15/2021 <br /> AqY <br /> LJ <br /> FcF���T <br /> SFO <br /> T <br /> c <br /> M�M�UNT� <br /> FNT <br /> DEPARTMENT USE ONLY <br /> Application Accepted By i—�f— �i�� Date Ir, Area h� Employee ID# <br /> Grout Inspection By Date F1 SPECIAL Well Permit <br /> Pump Inspection By Date F1 WAIVER Received <br /> Soil Boring Inspection B Date ZZ>ZA Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received Chec Amount ate Permit/ Invoice k Well ID# <br /> Codes Info AV. Remitted itService Re rest# <br /> K42 Isla, - <br /> EHD 4306 6/112019 WELL/PUMP PERMIT <br />