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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1866 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />NON-REFUNDABLE PERMIT www.s ov or /ehd EXPIRES 4 Y \Ssjjlll <br />EAR FROM DATE ISSUED <br />JOB ADDRESS �jS�r^.� ,\I Nuc\j nc,l cC j)jcNct Lc -1-7 CITY/ZIP AC,tttA 1)(I CI`>,)2c) <br />CROSS STREETC'0'% F '�' X7• -•� APN 00540007 PARCEL SIZE�_LAND USE APPLICATION# <br />OWNER NAME Sara Lct T} 1 T G PHONE :20(A J 2 '�7 15 <br />OWNER ADDRESS 847 N Cluff�Ave Ste B1 CITYISTATErzIP_Lodi, CA 9(�5240 <br />CONTRACTOR �( 111 e y `V t t 1 h f)°f PHONE/CLI } <br />CONTRACTOR ADDRESS T_�� _�-i' ,� CITY/STATE/Zip Gc) 't .1 -"(] I (, 7 ;y <br />SUBCONTRACTOR/CONSULTANT i PHONE <br />SUBCONTRACTOR/CONSULTANT ADDRESS CIITY/STATEZP <br />LICENSE AC -57 D C-61 D D-09 D Other NUMBER -Ia_ EXPIRATION DATE 1�y <br />BILLING PARTY: ❑ OWNER (CONTRACTOR D SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELLSAMPUNG: ❑ General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) ❑ Arsenic (4393) <br />INTENDED USE )IkDomesticlPrivate ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ 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 O Well Alteration/Modification D Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(S)# et borings ❑Geotechnical r or bo <br />,4 <br />� <br />13Out-Of-Service <br />��Of-Service Well ❑ Out -Of -Service Well Renewal Cross -Connection Re <br />Thew Pum D Pum Replacement D Pum Repair D Raise Well CasingP HEALTH D <br />WELL CONSTRUCTION <br />Drilling Method ';.Mud Rotary ❑ Air Rotary ❑ Auger r7 Cable Tool D Push Paint ❑ Other <br />Proposed Well Depth 44c7 ft Excavation 12 in diameter ❑ Open Bottom Gravel Pack/Gravel Size l% A in diameter <br />D Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched C 1-71 ti, ❑ Steel >,Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth I L t It D Neat Cement (94 /b bag/5-10 gal water) Sand Cement I j .:� sack mixl7 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method pumped D Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller D Pump Contractor D Other <br />Concrete Pedestal ODimensions: Width —g-� ft Length ---Q ft Thick in D Christy Box ❑Stove Pipe <br />Pt1MP 'l9.Submersible❑ Turbine ❑ Other HP Pump Se 1 it t ft Standing Water Level n�• �c I <br />mra e.—Iu Auvm Anu InAI Int WUKK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. 1 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 />1,il j,1Lj( jFtq 1;+.G AOUR ADVANCE NOTICE RI ---C 6 RFD FOR mataFCTinhm - PI I-Acr•• r'AI t r,3nnt <br />MENT <br />QED <br />201010 <br />PM TME 7Y <br />NT <br />Application Accepted By esar Ruvalcab Date 4/20/2020) Area 4/99 Employee ID# SK <br />Grout Inspection By� Dates /- G' 1 C ❑ SPECIAL Well Permit <br />Pump Inspection By Date ❑ WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />PE SC Info <br />Codes <br />Recelved Check#/ Amount <br />Cash Remitted <br />Date Permltl Invoice # Well ID# <br />Service Re uest M <br />4 <br />/D % $145 <br />4392 <br />70JQjZ <br />0 <br />4366 180 <br />420 <br />WP0040737 <br />4380 <br />2 <br />ZD WP 040738 <br />WELL /PUMP PERMIT <br />