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Site Address: 5433 E Harney Ln, Lodi CA 95240 Record ID: WP0041640 <br /> Date: 5/19/2021 <br /> PHOTO# 1 New Well. Well Log. Grouted from 200 ft usin 10.3 sand cement. <br /> TrRIP7PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)468-3420 <br /> [J J • <br /> NON-REFUNDABLE PERMIT ,t VJWW.S• ov.0 lehd EXPIRES 1 YEAR FROM DATE ISSUE N �-/r <br /> Joe ADDRESS 7 / �F-�LL l.� CITVIZIP I D J ;—Ie<T <br /> L,��L Z.!^ APN `)'1 l7Jr PARCEL SIZE/� LAND USE APPLICATION# m 7-' <br /> CROSS STREET L t <br /> �I'i/ /' % PHONE J(J L rNn_ <br /> OWNER NAME //�� \/• -.-. /�� <br /> OWNER ADDRESS <br /> CITYISTATEIZIP Sv ✓C�, / <br /> PHONE <br /> y7 <br /> CONTRACTOR �s i' �(] <br /> CITYISTATERJPC " +-'DIY �F / <br /> CONTRACTOR ADDRESS .-3 <br /> /.=.P .S PHONE �. / ! ` <br /> SUBCONTRACTOR/CONSULTANT� / r <br /> CITVISTATEOP ! S� �, <br /> SUBCONTRACTOR/CONSULTANT ADDRESS <br /> aeC$1 ❑D-09 ❑Other NUMBER 12 77 37'S EXPIRATION DATE ��� <br /> CENSE C-57 D ? 1/y/, <br /> LJ <br /> BILUNG PARTY: O OWNER ❑CONTRACTOR O SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WEU General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392)U Arsenic 4393 <br /> INTENDED USE a'�DomesticJ rlvate O InigatloNAgnCullu(al ❑Industrial D Water Quality mo;it <br /> IIoring O Soil Sam pling,Charactenzation <br /> ❑Public Water System ,N ,syelem Name Contex Name or Phone Number� �--- <br /> u dx1e2M trom Ower A) <br /> TYPE OF WORK XNew Well Replacement Well O Well Alteration/Modification O Other O Geotechnical <br /> • burin <br /> D Monitoring Wells) #of wells O Soil Boring(s) ,A / <br /> O Out-Of-Service Well D Out-Of-Service Well Renewal O Cross-Connection Repair JAN <br /> T <br /> ❑Raise Well Casmg <br /> yNew Pump ❑PumP Replacement ❑Pump RePalr f <br /> �===u <br /> _ JOAQP,iUIp U VG_ L Rotary O Air Rotary a Auger U Cabin Tool O Push Point ❑ Other lSizeDEPq ti%�ameter L y� S.•-�h O`-' R Excavation j L in diameter O Open Bottom ❑Gravel PacklGravel Size ��^�ITT / L— <br /> O Conductor r Casing In diameter / Conductor Casing Depth <br /> n <br /> I Well Casing Diameter�?in Thickness/GaugeIASTM Schad L-'= ❑Steel .liPlastic ❑Stainless Steel ❑Other 7 <br /> ft O Neat Cement 94 Ib bacyS10 981 water) ty6and Cement�v., sack mixR <br /> Grout Seal Depth n2 gal water / I <br /> O Bentonite(20%solids) O Other <br /> Grout Placement Method ePumped D Free Fall O Other ❑Retardant I Accelerator(name) �� •� N ,�� <br /> PEDESTAL installed By DAriter ❑Pump Contactor ❑ Other <br /> ❑Concrete Pedestal nDimerrstons�Wldlh ft Length fl ThIUc in O Christy Box ❑Stove Pipe ,•..� _ r e <br /> PUMP �Submersible0 Turbine ❑Other. HP Pump Set It Standing Water Level h <br /> 1 HEREBY CERTIFY THATd HAVE PREPARED THIS APPUCATION AND T({A7 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 LICCNSE-IS",.I. "-".- --�>-•ro:•� <br /> CURRENT ALI <br /> ND ACTIVE WITH THE CAFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. -. <br /> eeIN1IMl IM 41 HOU <br /> //ADVANCE NOTICE REQUIRED FOR <br /> INSPECTIONS-PLEASE CALL(209)953-7697 <br /> 7,y TITLE DATE <br /> 1 <br /> • e <br /> Francisco Garcia Ruiz, Environmental Health Asst. Page 1 of 2 <br />