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Site Address: 2475 Sargent Rd, Lodi CA 95240 <br />Date: 12/1/2021 <br />PHOTO # 1 New Well. Well Log. Well grouted from 100 ft using 10.3 sand cement. <br />:3 20- <br />WELL/PUMP PERMIT <br />4AN JOAOVIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT IAEA Feer--A.n—_C.......-.... n. ........ .. <br />JOB ADDRESS <br />Cnvra/�/iv�f Z6101 <br />CROSt STREET (/I APN QQ of PARCEL SUE IL LAND Use APPUCATION0 <br />OWNER NAME -:7 t' [J�(/f[ y�,L�. 11) np JC rolS PHONE 94�-o��y <br />OwnER ADDRESS <br />r S !Yi I i <br />cmBTATT1zro <br />CONTRACTOR (�/�}xx PHONe .33f`A- / [/.y <br />Z $� <br />CONTRACTORADDRESS 46W <br />a.r -'7fp IT <br />CYISTATE0P_V-f///'1kL'P <br />SuBCONTRACToWCONSULTANT !! G Aal d!/J moi PHoNe 3 2.7 - .i 110 <br />SUBCONTRACTORICONSULTANT ADDRESS CI-T�YIISSTATEMP <br />LICENSE AU C•57 D C-61 O D-09 0 Other NUMBER! Tiff EXMRAnONDATE & 2-3 <br />rw <br />BNo PARTY: O OWNER D-L`ONTRACTOR 0 SUBCONTRACTORICONSULTANT <br />DOMESTIC WELL SAMPLtNO:X General Mineral/Coliform Bacteria (4391)A Dbromochioropropsm (4392) 0 Arsenic (4393) <br />INTENDeo UBE KiDomesticlPrivate O IRlgetksUAgriwitural O Industrial 0 Water Quality Montlori g 0 Sot1 SamplinglCharaelertzatlon <br />0 Pubic Water System <br />rmn.Iau Avnf Owmr' W.Yr S"t— N— C -W Nem. a PTI N -b. <br />TYPE Or WORK Qew Well Pq Replammmt Well O Wen AReratlor&lodlfk Wn 0 Other <br />O Monitoring Wef(s) sof weft aSof 9oring(s) - *&b.Mt. 0Geotedvdral tdb.r p <br />0 Out-OfServics Well 0 Out -Of -Service V40 Renewal 0 Cross-Conneclim Repair <br />a <br />I)I Pump D Ptarlo Replacement 0- Puna Repair 0 Raise Wei Casing <br />Drilling Method X Mud Rotary O Air Rotary D Auger D Cable Tod 0 Push Point 0 DOW // - <br />Proposed Well Deplh� fl Excavation / -L in diameter 0 Open Bottom xrem 1-1— Slze�_ kt diameter <br />0 Condudor Casing In diameter I Conductor Casing Depth fl <br />Well Casing Diameter 16� in Tticl a .CatgefASTM Soiled L 20 0 Steel WPlestic D Stalnleas Steel 0 Other <br />Grout Seal Depth fl 0 Neat Cement (94 Po bsg,5� 10 gal wafer) 3' Send Cement 10,3 sack mlxf7 gal water <br />D Benlonite (20% eofds) 0 Other <br />Grout placement MethodAf Pumped 0 Free Fag O Other ❑ Retardant l Accekralo (menta) <br />PE=TAL - Installed By AY-OrIffer D Pump Contractor omen <br />O Concrete Pedestal ODlmmslons Width L 0 g Zth fl Thick in O Christy Hox ❑Stove Pipe <br />air �,Submerslbk0 TlxMrte 0 ether HP ^L. Pump Sel fl SlandIN Water Level 0 <br />_ 1 j"My CER7IFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THG MMK.Ill.r, BE DTHAT MY REQUIRED ONE IN ACCORDANCE WITH SAN <br />"BOULQ7pJ RElff AND ACTNE IMIIT}1C THESTATE CALIFORLAWS, CONTRACTORS IITATE NSE 18 <br />LICANDENSE BOAR'�Dp T�jIrA7 AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />MINIVIIA48 H'gUR ADVANCE NOTICE REQUIRE <br />hL1,D FOR INSPECTIONS -PLEASE CALL (209) 863-7697 <br />- <br />Francisco <br />OG✓Ni !` I DATE -�o -� �'/ <br />Francisco Garcia Ruiz, Environmental Health Specialist Trainee <br />Record ID: WP0042732 <br />s �-/ yr <br />993- <br />�19 ` SSW <br />j.(- <br />J V _ r <br />4 <br />l/ - 7 cT- <br />-7 6- a3- --Z <br />a y^ 7 ?- SX/4--6 w' <br />17 6�- / 0 IR- GlloI <br />j Oq - /6'-5- SM4 G1&?!/iil <br />17 61 --1 'S v Z' <br />7, 2 e,- 6w 4 ►ti <br />10 2- 3 °"s `'G% <br />30.3`-/ 3Ahe <br />l <br />Page 1 of 2 <br />