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/z()5 <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1$68 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232 (209)468-3420 <br /> NON-REFUNDABLE PERMIT WWW.sjgoy.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED_ <br /> JOB ADDRESS 14400 N. Curry Ave. CITY/ZIP Lodi/95240 m <br /> K D <br /> CROSS STREET E. Kettleman Ln. APN 061-13-227 PARCEL SIZE 9.99 LAND USE APPLICATION# o <br /> A <br /> OWNER NAME ,teff Perlegos Ave. PHONE 209-663-9069 y <br /> OWNER ADDRESS 155_06 N. Curry A __ CITY/STATE/ZIP <br /> Lodi/95240 <br /> CONTRACTOR Della Pump Inc PHONE 209-466-9625 <br /> CONTRACTOR ADDRESS 646 S. California St. CITY/STATE/ZIP Stockton/95203 <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP <br /> LICENSE i C-57 X C-61 D-09 Other NUMBER 1055434 ExpotAT1oN DATE 7/31/2021 <br /> BILLING PARTY: OWNER CONTRACTOR 1 SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING: -1 General MinerallColiform Bacteria(4391) -1 Dibromochloropropane(4392)-1 Arsenic(4393) <br /> INTENDED USE Il Domcstic:Privatc X Irrigation+Agricultural - Industrial Water Quality Monitoring f Soil SamplingrCharacterization <br /> U Public Water System <br /> If different from Owner. Water System Name Contact Name or Phone Numbc <br /> TYPE OF WORK U New Well I Replacement Well Well Alteration%Modification Other <br /> # <br /> D Monitoring Wells) #of wells - Soil Boringof Bonn ` <br /> `� <br /> Boring(s) I- Geotechnical •A�r <br /> fl Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair /N , <br /> J New Pump Pump Replacement X Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION D <br /> Drilling Method _� Mud Rotary L Air Rotary L1 Auger U Cable Tool _ Push Point Other SAN <br /> Proposed Well Depth 11 Excavation in diameter I; Open Bottom :I Gravel Pack; V/Ar.o_in diameter <br /> j Conductor Casing In diameter / Conductor Casing Depth It STH O MENT uNT 1' <br /> Well Casing Diameter_ in ThicknessGauge;ASTM Sched I' Steel Plastic Stainless Steell Otn��RT �� <br /> Grout Seal Depth It _ Neat Cement(94/b bagi/5-10 gal wate) _ Sand Cement sack mW7 gal water <br /> I Bentonite(20%solids) I Other <br /> Grout Placement Method Pumped .I Free Fall Other L: Retardant!Accelerator(name) <br /> PEDESTAL Installed By Driller Purnp Contractor - Other <br /> � Concrete Pedestal nDimensions Width R Length fl Thick in Christy Box rl Stove Pipe <br /> PUMPI SubrnersibleX Turbine _ Other HP�,� Purnp Set 130 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 /> /'//J.JUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL(209)953-769-l' <br /> SIGNED _ l/C/K4," TrrLE CEO _ DATE 21191°2021 <br /> f A •I �i �� T. .�1� " <br /> ' <br /> ,} { �� 'rs•,.. ihuss.'9Es 3..• �til�i <br /> i»iti iii. EEi 1 <br /> s <br /> i! ill <br /> J .11 <br /> .,f(}r7 <br /> c��!! (, .rr.• 7 I <br /> EPARTMENT U S E O L Y <br /> Applca[ion Accepted By Date y ) Area / Employee ID# <br /> rout Inspection By Date✓ ( I SPECIAL Well Permit <br /> Pump Inspection By Date �l 1 WAIVER Received <br /> Soil Ecring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC ReceivedCheck Amount Permit/ <br /> Codes Info Remitted Date Servi e R uest# Invoice# Well ID# <br /> EHD 43-05 691.trLOt9 .--- <br /> P+=LL:PUrt'I'I'FF'^Ali <br />