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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209)1468-3420 <br />NUN-KEFUNDABLE PERMIT WWWA <br />JOB ADDRESS 19 North Sacramento St <br />CROSS STREET W Pine St APN 04303513 <br />04303516 <br />OWNER NAME <br />OWNER ADDRESS <br />CONTRACTOR Neil O' Anderson and Associates <br />CONTRACTOR ADDRESS 902 Industrial Way <br />SUBCONTRACTOR/CONSULTANT Same as above PHONE Same as above <br />SUBCONTRACTORMONSULTANT ADDRESS Same as above CITY/STATE/ZIP Same as above <br />LICENSE x C-57 C-61 1 D-09 Other NUMBER #669004 EXPIRATION DATE 05/31/2023 <br />BILLING PARTY: OWNER D�CONTRACTOR SUBCONTRACTOR/CONSULTANT <br />1 TEAR FROM DATE 155UED <br />cITY/ZIP Lodi. CA <br />SIZE 0.1 aC LAND USE APPLICATION # <br />PHONE <br />CITY/STATE/ZIP <br />PHONE (209) 586-2219 <br />Cm/STATE/ZIP Lodi, CA 95240 <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />WENDED 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 Wells) # of wells Soil Boring(s) # of borings X Geotechnical 4 # of borings <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />PA <br />FC` M�Nr <br />Drilling Method Mud Rotary Air Rotary 11( Auger Cable Tool Push Point Other ' CL <br />Proposed Well Depth 25 ft Excavation 6 1/4" in diameter Open Bottom i Gravel Pack/Gravel Size in diamet <br />Conductor Casing in diameter / Conductor Casing Depth ft SAN Q(/ ?o2! <br />J <br />Well Casing Diameter in Thickness/Gauge/ASTM Schad Steel Plastic Stainless Steel .. Other !! <br />Grout Seal Depth 25 ft X Neat Cement (94 Ib bag16.10 gal water) Sand Cement sack mix/7/�shw� ONM CO(JN7. <br />Bentonite (20% solids) Other �pq�T tk ` l' <br />Grout Placement Method Pumped Free Fall Other Retardant / Accelerator (name) MENT <br />PEDESTAL Installed By Driller Pump Contractor I i Other <br />Concrete Pedestal I Dimensions: Width ft Length ft Thick in Christy Box i 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 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED :j TITLE Staff Engineer DATE 6/23/2021 <br />DEPARTMENT US NLY <br />Application Accepted By ad& Date Zd ZI Area 1 Employee ID# <br />Grout Inspection By V <br />V Date SPECIAL Well Permit <br />Pump Inspection By <br />Soil Boring Inspection By biwoADate <br />Date WAIVER Received <br />7/ Constructed Well Depth <br />COMMENTS <br />ft <br />NNUM Mj�p <br />� <br />jk <br />Amount Permit/ <br />' Service Request # <br />L���]►ll,�'!JF?��l?►� <br />� �otrill^�•I�il�i� <br />EHD 43-06 6/11/2019 WELL /PUMP PERMIT <br />