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*2`3" w <br />ELL/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 />JOB ADDRESS 12076 N. Jack Tone Rd. CITYmP Lodi/95240 <br />CROSS STREET Grassland Rd. APN 063-27-068 PARCEL SIZE 4.29 LAND USE APPLICATION # <br />OWNER NAME Kelly Thompson PHONE 209-993-3557 <br />OWNER ADDRESS SAME__.._ CITYISTATE/ZIP <br />CONTRACTOR Delta Pump Co. PHONE 2J09-466-9625 <br />CONTRACTOR ADDRESS 646 S. California St. CITY/STATE/ZIP Stockton/95203 <br />SUBCONTRACTOR/CONSULTANT PHONE <br />SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP <br />LICENSE 1 C57 X C-61 D-09 Other NUMBER 1055434 EXPIRATION DATE T-3 1;2021 <br />BILLING PARTY: OWNER CONTRACTOR I I SUBCONTRACTORICONSULTANT <br />DOMESTIC WELL SAMPLING: -1 General Mineral/Coliform Bacteria (4391) -1 Dibromochloropropane (4392) -1 Arsenic (4393) <br />INTENDED USE X Domestic.,Private -1 Irrigation;Agricultural - Industrial - Water Quality Monitoring F Soil Sampling.+Charactery5tion <br />I Public Water System 4 <br />If dlrrcront from Okwel_ Water System Name Contact Name or Phone Number <br />TYPE OF WORK IJ New Well I Replacement Well Well AlteratioriModification Other <br />1 Monitoring Well(s) # of wells - Soil Boring(s) * of bS1p1gs 1 Geotechnical <br />f1 Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair Sq 10 <br />J New Pump X Pump Replacement _I Pump Repair _ Raise Well Caslna .._ F �DAn, <br />1rT� <br />Dnllmg Method Mud Rotary L Air Rotary a Auger U Cable Tool _Push Point _ Other N"r,6MINT ��N"" TY <br />Proposed Well Depth ft Excavation in diameter I I Open Bottom i I Gravel PackiGravel Size Irratafieter <br />Conductor Casing in diameter f Conductor Casing Depth -It <br />Well Casing Diameter in Thickness 'Ga ugerASTM Sched I I Steel Plastic I Stainless Steel Other <br />Grout Seal Depth ft _ Neat Cement (94 Ib baglb-10 gal waterl _ Sand Cement sack mix.+7 gal water <br />I Bentonite (20% solids) I Other <br />Grout Placement Method _ Pumped J Free Fall Other U Retardant! Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor - Other <br />-1 Concrete Pedestal "IDimensions Width ft Length ft Thick in Christy Box '1 Stove Pipe <br />PUMP X Submersible Turbine _ Other HP 1 Pump Set 152 ft Standing Water Level 141 It <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 />M ' &4� ! H UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />m <br />SIGNTITLE CEO DATE 7/7A17f171 <br />Area Employee ID# -DA <br />1 SPECIAL Well Permit <br />1 WAIVER Received <br />Constructed Well Depth <br />iZ <br />PE <br />Codes <br />DEPARTMENT USE ONLY <br />`,-CheckALP Amount ate <br />a Remitted <br />/ J <br />Application Accepted By <br />Date <br />Grout Inspection By A <br />Date <br />Pump Inspection By <br />Date l <br />Soil Boring Inspection By <br />Date <br />COMMENTS <br />Area Employee ID# -DA <br />1 SPECIAL Well Permit <br />1 WAIVER Received <br />Constructed Well Depth <br />iZ <br />PE <br />Codes <br />SC Received <br />Info B <br />`,-CheckALP Amount ate <br />a Remitted <br />Permit/ Invoice # <br />Service Req nest # <br />Well ID# <br />�i3n <br />sem+ <br />-l"7— <br />l <br />EH0 43-06 01112019 <br />fJLL it Uiti 1' I'cK`AI I <br />T <br />M <br />D <br />v <br />v <br />A <br />rn <br />w <br />