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1 <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209) 468-3420 <br />NUN-KEFUNDABLE PERMIT L:ALL (LUy) yt)J-/by/ FOR INSPECTIONS <br />tJCYIKtJ l TEAR FROM UATE ISSUED <br />JOB ADDRESS 21200 North Davis Rd /2 (,`cf/V <br />A"• /)4#'/- efli, <br />Lodi/95242 <br />CROSS STREET W Peltier Road API 013-09-35&013-09-36 PARCEL SIZE 17.2889.35 LAND USE APPLICATION # <br />Celia Hung C/3 -(:r; (' � <br />c•'3-C"C -36 <br />OWNER NAME 9 <br />PHONE <br />OWNERADDRESS 157 California Reserve, 67667 Hwy 20 <br />CITY/STATE/ZIP <br />Bend/Oregon/97701 <br />CONTRACTOR North American Technical Services <br />PHONE 209 545-1108 <br />4713 Enterprise Way, Suite 4 <br />Modesto/Ca/95356 <br />CONTRACTOR ADDRESS <br />CITYISTATE/ZIP <br />SUBCONTRACTOR H1 Drilling <br />PHONE 916 213-7231 <br />SUBCONTRACTOR ADDRESS 1400 Kitchner Road <br />CITYISTATE/ZIP <br />Sacramento/CA/95822 <br />LICENSE X C-57 C-61 D-09 1- Other <br />NUMBER 1006095 <br />EXPIRATION DATE 8/31/23 <br />GEOGRAPHICAL INFORMATION: Coordinates X -121-329354 Y38-177291 Township _ Range Section <br />NTENDED USE I:: Domestic/Private :: Irrigation/Agricultural !:. Industrial Water Quality Monitoring )0 Soil Sampling/Characterization <br />F Public Water System <br />If different from Owner: Water System Name ontact Name or Phone Numoer <br />TYPE OF WORK I'. New Well :' Replacement Well Well Alteration/Modification IOther <br />❑ Monitoring Well(s) # of wells :.. Soil Boring(s) # of borings x Geotechnical L•, # of bonngs <br />L Out -Of -Service Well Out -Of -Service Well Renewal f: Cross -Connection Repair <br />raise vveu Uasi <br />Drilling Method C: Mud Rotary 'i:; Air Rotary X Auger ::. Cable Tool :: Push Point Other <br />Proposed Well Depth 50' Max ft Excavation 4" in diameter - Open Bottom :. Gravel Pack/Gravel Size in diameter <br />C'.. Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Schad Steel I. Plastic Stainless Steel Other <br />Grout Seal Depth ft Neat Cement (94 Ib bag/5-f0 gal water) I Sand Cement sack mix/7 gal water <br />I_'.. Bentonite (20% solids) :. Other Temporary geotechnical boring; grout backfilled per SJCEHD requirements upon completion <br />Grout Placement Method ::: Pumped Free Fall Other Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller :::: Pump Contractor Other <br />L'. Concrete Pedestal .!Dimensions: Width ft Length ft Thick in ':: Christy Box _. Stove Pipe <br />PUMP I 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 COMPENSA "IFAVWmr River Drive <br />MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED TITLE DATE <br />w <br />e- " DEPARTMENT UEN LY `,L-, <br />Application Accepted E t'' Date / �� Zj Area Employee ID# WA <br />Grout Inspection By Date ❑ SPECIAL Well Permit <br />Pump Inspection By Date y ❑ WAIVER Received <br />Soil Bon ngspection By Date , Constructed Well Depth ft <br />COMMENTS / b,'• 0e) J3 hJ -'i-s , el-? -- (,V0 --36 <br />PE SC Received Check#/ <br />Codes Info B Cash <br />Amount <br />Remitted Date <br />Permit/ <br />ServiceRequest # Invoice # Well ID# <br />4/30112 <br />� 132 -off, 3,;4 <br />/ <br />EH D 43-06 <br />�., <br />WELL /PUMP PERMIT <br />4/30112 <br />� 132 -off, 3,;4 <br />/ <br />'04 <br />y <br />