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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE- STOCKTON CA 95205-6232 (209)466-3420 <br />NUN-KEFUNDABLE PERMIT www.sjgov.org/elici LXPIKL5 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS " tt17'h-9t 1633 Kettleman Lane addCIn•2jp Lodi/95242 <br />CROSS STREET Lakeshore Dr ApN 03133010 & 03133009 PARCEL SIZE 0.58.1.17- LAND USE APPLICATION # <br />OWNER NAME Parc Construction PHONE 209-689-6241 <br />OWNER ADDRESS 4523 S B St CITY/STATE/7,p Stockton/CA/95206 <br />CONTRACTOR West Coast Exploration Inc PHONE 209-985-7541 <br />CONTRACTOR ADDRESS P.O. Box 133 CITY/STATEILp Escalon/CA/95320 <br />SUBCONTRACTOR/CONSULTANT CTE CAL Inc PHONE 209-543-1799 <br />SUBCONTRACTOR/CONSULTANT ADDRESS 4230 Kiernan Ave Ste 150 CITYISTATEIZIP Modesto/CA/95356 <br />LICENSE x C-57 C-61 D-09 Other NUMBER 870761 EXPIRATION DATE 01/31/2022 <br />BILLING PARTY: OWNER CONTRACTOR X SUBCONTRACTORICONSULTANT <br />DOMEsnc 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 Wells) # of wells Soil Boring(s) # of borings X Geotechnical 2 a of borings <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />3rilling Method Mud Rotary Air Rotary x Auger Cable Tool Push Point Other <br />proposed Well Depth 10 It Excavation 4 Inches in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br />Grout Seal Depth 10 ft x Neat Cement (94 Ib bag/5-10 gal water) Sand Cement sack mixf7 gal water <br />Bentonite (20% solids) Other <br />3rout Placement Method Pumped X Free Fall Other Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor Other <br />Concrete Pedestal Dimensions: Width It Length ft Thick in Christy Box 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 /�� �/L��If� TITLE Staff Geologist DATE 9/2/2021 <br />DEPARTMENT US ONLY <br />Application Accepted By ate q131-7 Area Y "�Employee ID#Wk <br />Grout Inspection By YDate / SPECIAL Well Permit <br />Pump Inspection By ate WAIVER Received <br />Soil Boring In action By ate onstructed Well Depth ft <br />COMMENTS/QiN ►'� C Otoe, <br />Ci i0 i I cYOUI°Y 5 t'i7t r J-ff'y <br />PE SC Received Check#/ <br />Codes Info Cash <br />Amount D Permitil # Well ID# <br />Remitted e Service Re ues # <br />37 o w— <br />O <br />EHD43-06 6111/2019 &V WELL (PUMP PERMIT <br />