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I' WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />�.vr.-r.crurrusaoLr_rtrcml I FALL (LU`J) U04-fb`lf FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 14658 E. Live Oak CITY/ZIP Lodi. 95240 <br />CROSS STREET Jack tone Rd APN 06530002 /1) L PARCEL SIZE LAND SE APPLICATION # <br />OWNER NAME Javier Perez I l' P, f Q I1 A <br />PHONE <br />OWNER ADDRESS Po Box 790 <br />CONTRACTOR GOLDEN STATE IRRIGATION & PUMP SERVICE <br />CONTRACTOR ADDRESS 4500 E FREMONT <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE ❑ C-57 Q C-61 ❑ D-09 ❑ Other <br />CITY/STATE/ZIP Lodi. CA 95240 <br />PHONE 209-943-7774 <br />CITY/STATE/ZIP STOCKTON. CALIF 95215 <br />PHONE <br />CITY/STATE/ZIP <br />NUMBER 979633 EXPIRATION DATE 12/31/22 <br />DOMESTIC WELL SAMPLING: 0 General Mineral/Coliform Bacteria (4391) 0 Dibromochloropropane (4392) 0 Arsenic (4393) <br />INTENDED USE ❑ Domestic/Pdvate 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 />I YPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s)# of borings of • , <br />❑Geotechnical c JV <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal 0 Cross -Connection Repair C CE/ Vej <br />0 New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casino V <br />Drilling Method 11Mud Rotary 0 Air Rotary ❑ Auger ❑ Cable Tool 0 Push Point ❑ Other MAR <br />O 202 <br />Proposed Well Depth ft Excavation in diameter 0 Open Bottom D Gravel Pack/Gravel Ss a 0A /� mete <br />❑ Conductor Casing _ in diameter / Conductor Casing Depth _. _ ft HEqLT-Hp q&I NrU <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic I7 Stainless Steel ❑ Other EPARTMc. <br />Grout Seal Depth ft ❑ Neat Cement (94 /b bag/5-10 gal water) ❑Sand Cement sack mix17 gal a e <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method D Pumped ❑ Free Fall ❑ Other 0 Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />❑ Concrete Pedestal DDimensions: Width ft Length ft Thick <br />in ❑ Christy Box ❑ Stove Pipe <br />( PUMP q Submersible ❑ Turbine ❑ Other HP 10 Pump Set 210 ft Standing Water Level 160 ft <br />Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect to the following items: GPS <br />Coordinates, property lines, adjoining properties, water bodies or courses, drainage pattern, roads, existing wells, structures, <br />potential sources of contamination, sewers or private disposal systems. Include distance from two property lines. For Domestic, <br />Agriculture, Industrial well, provide location of any water wells or surface water within 200' radius of proposed well. <br />N'IINEVIUM 24 TIOUR ADVANCE NOTICE!; REQPIRE'D FOR INSPECTIONS - I'LFASI' CAL:L.. (209) 953-7697 <br />Application Accepted By <br />DEPARTMENT USE ONLY <br />�- Z_ L <br />Date 3 .?,2 <br />Grout Inspection By Date <br />Pump Inspection By 117LDate <br />Area `� V! Employee ID# f f"1tq <br />k. <br />SPECIAL Well Permit <br />❑ WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS /veW Ir vle bpirmell WPo041JE-3 <br />PE <br />Codes <br />SC Received QChec_W <br />Info B ash <br />Amount <br />RemittedDate <br />Permit/ <br />Servi a Re uest # Invoice # Well ID# <br />990 <br />CI') <br />/fid <br />2 <br />EHD043-06 10/25/2021 Page I of 2 Well / Pump Permit <br />