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WP0042340
EnvironmentalHealth
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4200/4300 - Liquid Waste/Water Well Permits
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WP0042340
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Entry Properties
Last modified
12/10/2021 11:48:08 AM
Creation date
12/10/2021 10:55:12 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
WP0042340
PE
4381
STREET_NUMBER
15491
Direction
N
STREET_NAME
LOCUST TREE
STREET_TYPE
RD
City
LODI
Zip
95240-
APN
05113044
ENTERED_DATE
7/26/2021 12:00:00 AM
SITE_LOCATION
15491 N LOCUST TREE RD
P_LOCATION
99
P_DISTRICT
004
QC Status
Approved
Scanner
SJGOV\tsok
Supplemental fields
CYEAR
2021
Tags
EHD - Public
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1672 <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />rrvry r�crurvIJAMILt rLKMII WWW.S Ov.Or /enQ EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 15491 N. Locust Tree Ln. CITY/zIP Lodi/95240 _ <br />CROSS STREET Newfield Rd. APN 051-13-044 PARCEL SIZE 2.75 LAND USE APPLICATION # <br />OWNER NAME Jason Stalnaker PHONE 4_0.8-5.8.2-3507 <br />OWNER ADDRESS SAME CITYISTATE/ZIP CC � G <br />CONTRACTOR Delta CPump Co PHONE 209-466-9625 <br />CONTRACTOR ADDRESS 646 S. California St. CITY/STATE/ZIP Stockton/95203 <br />SUBCONTRACTOR/CONSULTANT <br />SUBCONTRACTORICONSULTANT ADDRESS <br />CITYISTATE/ZIP <br />-ICENSE I C-57 X C-61 D-09 Other NUMBER 1055434 <br />31LLING PARTY: OWNER CONTRACTOR 1 I SUBCONTRACTORICONSULTANT <br />PHONE <br />EXPIRATION DATE -+'31,12021 <br />DOMESTIC WELL SAMPLING: -1 General Mineral/Coliform Bacteria (4391) -1 Dibromochloropropane (4392) -1 Arsenic (4393) <br />INTENDED USE )k Domestic:Private -1 IrrigatiorvAgricultural - Industrial - Water Quality Monitoring r' Soil SamplingiCharacterization <br />Public Water System <br />I dr'ferert'rerr r_l•,vrei. Water Spstem Narrv_ Contac) Name or Phone Number <br />TYPE OF WORK U New Well I Replacement Well Well AlteratioriiModification Other d VN <br />rl Monitoring Well(s) # Of wells - Soil Boring(s) a °t honrq` I- Geotechnical . _-,R' c N, <br />1 Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair e�'C/Vj� <br />.1 New Pump {Pump Replacement .1 Pump Repair Raise Well Casinq of ,. <br />WELL CONSTRUCTION 16 C/Am <br />Drilling Method -j Mud Rotary L Air Rotary A Auger U Cable Tool Push Point Other SAN <br />Proposed Well Depth ft Excavation in diameter I I Op en Bottom i I Gravel Pack:Grave LNVi f7 <br />Conductor Casing in diameter .1 Conductor Casing DepthIt "' DEPA N7 -AL <br />Well Casing Diameter _ in Thick ness�Gauge:ASTM Sched I Steel Plastic I Stainless Steel Other R'TMFNT <br />Grout Seal Depth ft Neat Cement j94 tb bacyr 10 gal water] Sand Cement sack rrrrx!7 gal water <br />I Bentonite (20% solids) Other <br />Grout Placement Method _ Pumped J Free Fall Other L Retardant! Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor Other <br />' Concrete Pedestal -(Dimensions Width ft Length ft Thick in Christy Box 'l Stove Pipe <br />PUNS XSUbrnersible Turbine _ Other HP.1.5 Pump Set 138 it Standing Water Level _12Q ft ji <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 />! / / UR ADVANCE NOTICE RLQUIRED FOR INSPECTION6 - i'LLASE CALL (209) 953-7597 <br />SIGNED_ (4 ( Trr E CEO DATE 7/19/2021 <br />DEPARTMENT USE ONLY <br />i <br />Application Accepted By Date ° Area L G� Employee ID# U✓� <br />Grout Inspection By 4 Date I SPECIAL Well Permit <br />Pump Inspection By ri Date " tot I _ J WAIVER Received <br />Soil Boring Inspection By <br />COMMENTS <br />Date <br />Constructed Well Depth <br />m <br />PE <br />Codes <br />SC Received heck Amount <br />Date <br />Info B ash Remitted I I <br />Permit/ <br />Invoice # <br />rvice 5iquest # <br />Well ID# <br />� <br />n <br />EHD 43-W 61-1.,'2019 ;V =LL /PUMP I'EWAIT <br />
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