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WELUPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />NUIV-KEFUNDABLE PERMIT www.$)gov.org1en0 LXPIRE5 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 8000 E Kettleman CrrY1ZIP Lodi, CA 95420 <br />CROSS STREET ktTfie RR,d, ,�,i.1 4` i (' APN 06113338 PARCEL SIZE _j, BLAND USE APPLICATION # <br />OWNERNAME—T�-L�S�--_U-'�+P��se$.�-' 11 3 Vctre►1e -r L�/ PHONE <br />OWNERADDRESS PO BOX 1270 C"STATEI7JPLod ].,CA 95241 <br />CONTRACTOR Purviance Drillers, INC p,ONe209-887-3554 <br />CONTRACTOR ADDRESS P- 0 . BOX 64 CIrr/STATEMPL i nden CA 95236 <br />SUBCONTRACTORICONSULTANT <br />TANT ADDRESS <br />LICENSE X C-57 :; C-61 D-09 <br />BILLING PARTY: C OWNER <br />CITYISTATEMP <br />Other NUMBER 377923 EXPIRATION <br />CONTRACTOR SUBCONTRACTOR/CONSULTANT <br />7/31/21 <br />DOMEsnc WELL SAMPLING: G General Mineral/Coliform Bacteria (4391) _ 1 Dibromochloropropane (4392) C Arsenic (4393) <br />INTENDED USE ❑ Domestic/Private rrigation/Agricuttural C Industrial ❑ Water Quality Monitoring -.7 Soil SamplingtCharacterization <br />Public Water System <br />If different from Owner Water System Name Owtact Name or Phone Number <br />TYPE OF WORK _ New Well C Replacement Well -,, Well AfteratioNModification ❑ Other <br />Monitoring Well(s) # of wells _ Soil Boring(s) # of borings �i Geotechnical # of borings <br />5 Out -Of -Service Well ❑ Out -Of -Service Well Renewal I Cross -Connection Repair <br />Drilling Method _- Mud Rotary Air Rotary Auger , Cable Tool -: Push Point -- Other <br />Proposed Well Depth ft Excavation in diameter iI Open Bottom LI Gravel Pack]Gravel Size in diameter <br />_: Conductor Casing in diameter I Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Schad i Steel Plastic L Stainless Steel ❑ Other <br />Grout Seal Depth ft ; I Neat Cement (94 lb baglSiO gat water) G Sand Cement sack mix7 gal water <br />Bentonite (20% solids) ❑ Other <br />Grout Placement Method _: Pumped Lj Free Fall C Other Retardant / Accelerator (name) <br />PEDESTAL Installed By r Driller Pump Contractor U Other <br />Concrete Pedestal [;Dimensions: Width ft Length It Thick in C Christy Box D Stove Pipe <br />PUMP i- Submersibley TurbinA _ Other HP --IS Pump Set\,SpjZ ft Standing Water Level l fl <br />I HEREBY CERTIFY THAT 1 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 />DEPARTMENT USE ONLY <br />Application Accepted By Date ��' I Area L� �I (` Employee ID# <br />Grout Inspection By Date D SPECIAL Well Permit <br />Pump Inspection By Date CI WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS �,A N r'V w`��..tw� <br />IAYMENT <br />;ECEIVE® <br />AN 12 2021 <br />JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />EHE)43-06 6!11(2019 <br />WELL (PUMP PERMIT <br />r57.' <br />