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JOB ADDRESS <br />CROSS STREET N <br />7200 W Woodbridge Road crnalp Lodi, CA, 95242 <br />Van Exel Road APN 01 1-1 90-1 0 0/0 11-09 2-1 90 PARCEL SIZE ?C/ LAND USE APPLICATION # <br />OWNER NAME <br />OWNER ADDRESS <br />CONTRACTOR <br />Van Exel Dairy -Wet.ry Carolyn Vo 0 E A e ) 1.- g PHONE <br />7200 W Woodbridge Road CITY/STATFYLIP Lodi, CA, 95242 <br />BSK Associates PHONE 209-769-4734 <br />CONTRACTOR ADDRESS 550 W Locust Avenue CITY/STATE/ZIP Fresno, CA, 93650 <br />SUBCONTRACTOR/CONSULTANT BSK Associates PHONE 209-769-4734 <br />SUBCONTRACTOR/CONSULTANT ADDRESS 550 W Locust Avenue Crre/ST4TE/ZiP Fresno, CA, 93650 <br />LICENSE X C-57 0-61 D-09 Other NUMBER 490942 EXPIRATION DATE 12/31/2021 <br />BILLING PARTY: OWNER X CONTRACTOR SUBCONTRACTOR/CONSULTANT <br />Area q q/ Employee ID# AI A <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth <br /> <br />ft <br />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 />DOMESTIC WELL SAMPUNG: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE Domestic/Private Irrigation/Agricultural Industrial 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 Replacement Well <br />Monitoring Well(s) # of wells <br />Out-Of-Service Well <br />New Pumo Pumo Reolacement <br />Well Alteration/Modification Other <br />Soil Boring(s) Sof borings X Geotechnical 4x15'sofb°11ngs <br />Out-Of-Service Well Renewal Cross-Connection Repair <br />Pumo Reoair Raise Well Casino <br />WELL CONSTRUCTION <br />Drilling Method Mud Rotary Air Rotary x Auger Cable Tool Push Point Other <br />Proposed Well Depth 15 ft Excavation 4" 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 15 ft X Neat Cement (94 lb bag/5-10 gal water) Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method Pumped Free Fall <br /> <br />Other Retardant / Accelerator (name) <br />PEDESTAL <br /> <br />Installed By Driller Pump Contractor Other <br />Concrete Pedestal Dimensions: Width ft 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 />SIGNED 09/17/2021 <br />MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br /> <br />.../Z 74' TITLE GEO Group Manager DATE <br /> <br />1 <br /> <br />84 <br /> <br />e_ <br /> <br />Aftek A ••• <br /> <br />DEPARTMENT USE NLY <br /> <br />Application Accepted By <br /> 1 <br />Date .7 7 <br /> <br />Grout Inspection By Date <br /> <br />Pump Inspection By Date <br /> <br />Soil Boring Inspection By Date <br />COMMENTS <br />PE <br />Codes <br />SC <br />info <br />Received Check#/ <br />, <br />Amount <br />Remitted <br />Permit/ <br />Service Request # Invoice # Well ID# <br />4 37 07 1S 0 4 e ///. <br />rCaSk: Ae di r 49/2 <br />„pate' <br />4 irm oupooL0-571- <br />/1 • , <br />EHD 43.06 6/11/2019 <br /> /3/7 ?753 <br /> WELL /PUMP PERMIT