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I WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT . 1868 EAST HAZELTON AVENUE - STOCKTON CA 96206 - (209) 4614420 <br />NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />ciraip . Lodi California <br />J08 ADDRESS <br />CROSS STREET be, Ero cio ; APN PARCEL SIZE i f LAND USE APPLICATION ft <br />JJ <br />14700 Thornton Road LLC PHONE (208) 334-6583 <br />P.O. Box 1450 (7er (.1 F-e:or o:1 t (";‘,, `,.2) erryisTATEgip Lodi, CA 05241 q519.140 <br />Krazan & Associates, Inc. PHONE <br />559-348-2200 <br />CONTRACTOR ADDRESS <br />215W. Dakota Avenue CITY/STATE/ZIP Clovis, CA 93612 <br />OWNER NAME <br />OWNER ADDRESS <br />CONTRACTOR <br />14700 Thornton Road <br />PHONE <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />NUMBER 499908 10/31/2022 <br />UCENSE X C-57 0 C-61 0 D-09 0 Other EXPIRATION DATE <br />DomEsTic WEU. SAMPLING: 0 General Mineral/Coliform Bacteria (4391) 0 Dibromcichloropropane (4392) 0 Arsenic (4393) P,4 <br />0 Public Water System <br />Water System Name <br />TOM OF WORK 0 New Well 0 Replacement Well 0 Well Alteration/Modification 0 Other <br />0 Monitoring Well(s) * of wells 0 Soil Boring(s) *of borings X Geotechnical 5 ilieRobtoteN CO <br />a Out-Of-Service Well 0 Out-Of-Service Well Renewal 0 Cross-Connection Repair (10-50-Fedzikp'Wv7A <br />0 New Pump 0 Pump Replacement 0 Pump Repair 0 Raise Well Casing <br />CITY/STATE/ZIP <br />INTENDED Us t 0 Domestic/Private 0 Irrigation/Agricultural 0 Industrial 0 Water Quality Monitoring 0 Soil Sampling/Charade <br />If efferent from °velar. <br />Contact Name or Phone Number IIPR 0 , <br /> 4122 <br />HP <br /> Pump Set ft Standing Water Level <br /> ft <br /> .iIMIIM111111111 <br />Area 'If/ (!. ( Employee ID* <br />0 SPECIAL Well Permit <br />El WAIVER Received <br />WELL CONSTRUCnON <br />Drilling Method 0 Mud Rotary 0 Air Rotary 0 Auger 0 Cable Tool 0 Push Point 0 Other <br />Proposed Well Depth I ,...) - --) ft Excavation in diameter D Open Bottom 0 Gram! Pack/Gravel Size in diameter <br />0 Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched 0 Steel 0 Plastic 0 Stainless Steel 0 Other <br />Grout Seal Depth ') - —' ft X Neat Cement (94 lb begt5-10 gal water) 0 Sand Cement sack ntel gal water <br />0 Bentonite (20% solids) 0 Other <br />Grout Placement Method 0 Pumped 0 Free Fall 0 Other 0 Retardant / Accelerator (name) <br />-PeOES114, Installed By 0 Driller 0 Pump Contractor 0 Other <br />0 Concrete Pedestal ODImensions: Width ft Length <br />in 0 Christy Box 0 Stove Pipe <br />ft Thick <br />0 Submersible 0 Turbine 0 Other <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 />MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS -, PLEASE CALL (209) 953-7697 <br />1111111111111111111110' <br />DEPARTMENT USE ONLY <br />. , , <br /> <br />Application Accepted By c'-'--F-----.2-1;--- Date i 14".--• i <br /> <br />Grout Inspection By Date <br /> <br />Pump Inspection By Date <br />--- Soil Boring Inspection By/1 '^,46erc, ACM 677 Date -.6------0'?" ,Constructed Well Depth <br />COMMENTS -rit , MI N. 7T,-) t:A: C :;f , d i ( rmit. r) ( . 111, ,,1 3%) 6';,e i a r F 2. J c -" i-, ;NI ev,,,,,-- l' ' IS f• <br />PE SC Receivedtrek) <br />Codes Info By h <br />Amount <br />Remitted Date Permit/ <br />Service f3equest ti <br />Invoice ti. Well ID/ <br />.-/ 3702 /S-0 (l1&'-- ,3S--W,4 .t /c)i- / <br />'7—, <br />VI 11 JA ) 'CA') 't't, <br />Ef1D043-06 10125)2021 Well I Pump Permit Page o(2