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cn,llsTATea, Lodi, CA 95240 <br />CONTRACTOR ADDRESS 902 Industrial Way <br />BILUNO PARTY: 3 OwNIM XCONTRACTOR SUBCONTRACTOR/CONSULTANT <br />Wow System Name <br />INTENDED USE I ; Domestic/Private 1 Irrigation/Agricultural . Industrial Water Quality Monitoring X Soil Sampling/Characterization <br />Public Water System <br />differonl honk Owner. <br />CT Retardant / Accelerator (name) <br />Wem.Cousreucnoti <br />Drilling Method X Mud Rotary 7. Air Rotary . Auger I Cable Tool Push Point 0 Other <br />Proposed Well Depth 50 ft Excavation 6 114" in diameter Open Bottom !I Gravel Pack/Gravel Size In diameter <br /> <br />- Conductor Casing in diameter I Conductor Casing Depth <br />Well Casing Diameter In Thickness/Gauge/ASTM Sched .3 Steel 0 Plants _ Stainless Steel i Other <br />Grout Seal Depth 50 ft X' Neal Cement (94 lb bag/5-10 gal water) Sand Cement sack rnix17 gal water <br />Bentonite (20% solids) I Other <br />Grout Placement Method XPumped 0 Free Fall t/ Other <br />TYPE OF WORK 11 New Well 1 Replacement Well 0 Well Alteration/Modification LI Other <br />1] Monttoring Well(s) 0 of welts 0 Soil Boring(s) C db."' X. GeOtechnICE11 1 • °' ...T'Es <br />3 Out-Of-Service Well 7 Out-Of-Senrice Well Renewal 1 CTOSS-COnneCtiOn Repair <br />tt New Pump ) Pump Replacement 1 Pump Repair 0 Raise Well Casing <br />Jos ADDRESS 89 D'Arcy Parkway <br />CROSS SniEET S Harlan Rd Apa 19824049 <br />OWNER NAME Kr I lsy rk LL C <br />OWNER ADDRESS lq 1 I Fon P- <br />Neil 0' Anderson and Associates <br />CONTRACTOR <br />cmazie Lathrop, CA <br />PARCEL SIM 6_24 ac LA. USE APPUCATIOR <br />PHAN8 <br />p-a)-, q5-3‘4. <br />PRONE (209) 588-2219 <br />SUBCONTRACTOR/CONSULTANT Same as above PR., Same as above <br />SUSCONTRACTOR/CONSULTAPIT ADDRESS Same as above crrasmemp Same as above <br />LICENSE X' C-57 0 C41 C 0-09 " Other NUMBER #669004 Exp.,. DATE 05/31/2023 <br />DOMESTIC WELL SAMPUNO: 3 General Mineral/C.018.MM Bacteria (4391)1 Dibromochioropropane (4392) (I Arsenic (4393) <br />CITY/STATE/21P <br />Contact Nemo or Phone Number <br />PEDESTAL Installed By ' Driller C Pump Contractor 7 Other <br />Concrete Pedestal ODInsensIone, Width ft Length ft Thick in 3 Christy Box Stove Pipe <br />PUMP SUDMETSIble.2 Turbtne I Other HP Pump Set ft Standing Water Level <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 UCENSE BOARD AND THAT I AM IN COMPUANCE WITH ALL <br />WORKERS COMPENSATION LAWS <br />MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SiONNO_Xid 1, - TRU Staff Engineer Deye 9/27/2021 <br />MENT <br /> RECEIVED <br />0 1 2021 <br />QUIN COUNTY <br />ONMENTAL <br />DEPARTMENT <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAEELTON AVENUE - STOCKTON CA 95205 4232 (209) 468-3420 <br />NON-REFUNDABLE PERMIT ve.vw.s ov.or iehd EXPIRES 1 YEAR FROM DATE ISSUED <br />DEPARTMENT USE ONLY <br /> <br />Applicelhan Accepted By <br /> <br />Grout Inspection By <br /> <br />Soil Boring Inspection By <br /> <br />Pump Inspection By <br />COMMENTS <br />Area 3/1-61ttllinninima IDS AS <br />7 SPECIAL Well Permit <br />31 WAIVER Received <br />Constructed Well Depth <br />DI. <br />DeW <br />DEW <br />Dote ,AV .g ft <br />PE <br />Codes <br />SC <br />Info <br />Reathoed <br />Ely <br />CheekIN <br />Cash <br />Amount <br />Remitted Dile PennIU <br />Service Remenit S Invoke II Well IDS <br />11370 I5o 32_17/ 49S-C, lo-I-2.1 WPc0-12.(pci-i <br />„ti&.2. <br />ENO ANN 0/I1/1019 WELL /PUMP PERMIT