Laserfiche WebLink
1- WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN-KEFUNDABLE PERMIT GALL (ZUVJ V0J-/bVf FOR INSPECTIONS tAVIKtb l If EAR FROM WATL ISSUED <br />JOB ADDRESS 2611 REYNOLDS RANCH PKWY CITY/ZIP Lodi,CA <br />CROSS STREET E Harney Ln fyAPN 058-66-018 PARCEL SIZE LAND USE APPLICATION # <br />OWNER NAME SLj4t p in r � i 64ker G7 ovp LLL PHONE <br />OWNER ADDRESS dad fgdls Ave Sy+'fe /I� CITY/STATE/ZIP Loci; a�0?�a <br />CONTRACTOR Technicon Engineering Services, Inc. PHONE 559-276-9311 <br />CONTRACTOR ADDRESS 4539 N. BraWley Ave. Suite 108 CITY/STATE/ZIP Fresno, CA 93722 <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE 'R C-57 n C-61 [1 D-09 ❑ Other <br />CITY/STATE/ZIP_ <br />NUMBER 767888 <br />PHONE <br />EXPIRATION <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE 0 Domestic/Private 0 Irrigation/Agricultural [7 Industrial Water Quality Monitoring K Soil Sampling/Characterization <br />0 Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK ❑ New Well ❑ Replacement Well [l Well Alteration/Modification 17 Other <br />❑ Monitoring Well(s) # of wells fj� Soil Boring(s)) # of borings Geotechnical 5 # of borings PA Y <br />❑ Out -Of -Service Well p Out -Of -Service Well Renewal ❑ Cross -Connection Repair R�C ►{� <br />11 New Pump [] Pump Replacement Ii Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method I I Mud Rotary Cl Air Rotary Auger ❑ Cable Tool a Push Point t I Other <br />Proposed Well Depth 0-50' ft Excavation4'' in diameter f 1 Open Bottom [-I Gravel Pack/Gravel Size q�e <br />[I Conductor Casing in diameter / Conductor Casing Depth ft HR QrJ/N <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched [7 Steel 0 Plastic ❑ Stainless Steel ❑ OtherA�TN pn7En <br />Grout Seal Depth n —SO' ft ,Neat Cement (94 lb bag/5-10 gal water) D Sand Cement sack mix17 gal <br />[I Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall 0 Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller 0 Pump Contractor fl Other <br />❑ Concrete Pedestal [!Dimensions: Width ft Length ft Thick <br />n ❑ Christy Box I l Stove Pipe <br />PUMP ❑ Submersible[:] Turbine I:] Other HP Pump Set ft Standing Water Level 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 />MINIMUM 24 1-IOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By _A t <br />COMMENTS Tremie ioIDQ 'tom be ui <br />DEPARTMENT USE ONLY <br />Date r/a <br />Date <br />Date <br />Date <br />Area y ' Employee ID# F1yY4 <br />SPECIAL Well Permit <br />F WAIVER Received <br />Constructed Well Depth ft <br />foUrldw, }Cr ,s ehc4uy,4vre <br />mm <br />D <br />C3 <br />0 <br />m <br />N <br />to <br />� <br />r <br />PE SC ReceivedC Amount Date <br />Codes Info By, Cash Remitted <br />Permit/ Invoice # Well ID# <br />Service Request # <br />37a I so O69 � 'ZI 11'-Lldl7 <br />�' <br />EHD043-06 04/07/2022 Page I of 2 Well / Pump Permit <br />Ty <br />