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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 />NUN-KEFUNDABLE PERMIT GALL (YUyI U04-/bUt FOR INSPECTIONS r_ArIKtJ 1 TEAR FROM DATE ISSUED <br />JOB ADDRESS Auto Center Road & Pixley Parkwway Q CITY/ZIP Lodi, CA q Z L (1 <br />CROSS STREET J�i X kms`( ��APN ?>Q O ✓ sr� PARCEL SIZE ?-1-q <br />1• ` I LAND USE APPLICATION # <br />City of Lodi 209-333-6706 <br />OWNER NAME PkiONE <br />OWNER ADDRESS 221 W. Pine Street CITY/STATEIZIP Lodi, CA <br />CONTRACTOR <br />Krazan & Associates, Inc <br />CONTRACTOR ADDRESS 215 W. Dakota Avenue <br />SUBCONTRACTOR Krazan & Assoviates, Inc <br />SUBCONTRACTOR ADDRESS 215 W. Dakota Avenue <br />LICENSE X C-57 I i C-61 CI D-09 Il Other <br />PHONE 559-348-2200 <br />CITY/STATE/ZIP Clovis, CA 93612 <br />PHONE 559-348-2200 <br />CITY/STATE/ZIP Clovis, CA 93612 <br />NUMBER 499908 EXPIRATION DATE 10.31.2022 <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE Domestic/Private 1. i Irrigation/Agricultural Industrial Water Quality Monitoring . I:I Soil Sam piing/Characterization <br />Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK i New Well ❑ Replacement Well Well Alteration/Modification Other <br />Monitoring Well(s) # of wells C Soil Boring(s) u of borings X Geotechnical 6 # of borings <br />Out -Of -Service Well I Out -Of -Service Well Renewal Cross -Connection Repair (10-50 Fee <br />New <br />New Pum [:) Pum Replacement I I Pum Repair Raise Well CasingA <br />WELL CONSTRUCTION E+ <br />Drilling Method Mud Rotary Ci Air Rotary I ' Auger : Cable Tool C: Push Point Other <br />Proposed Well Depth ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size d I1r+Jp diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft 1$ ' W, `d ?0�� <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel I ; <br />Grout Seal Depth ft X Neat Cement (94 lb bag/5-10 gal water) Sand Cement N� 9ifRp�/� fal(g <br />Bentonite (20% solids) Cl Other NDE NTq <br />Grout Placement Method C; Pumped Li Free Fall Li Other Retardant / Accelerator (name) EN <br />PEDESTAL Installed By f11 Driller C' Pump Contractor Other <br />Concrete Pedestal (:!Dimensions: Width ft Length ft Thick <br />in Christy Box l Stove Pipe <br />PUMP Submersiblel:' 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 />MINIRICIt 24 IIOUR ADVANCE NO I ICI: REQ1-IRED I',Oil INSPECTIONS - P1 EASE C'111. (209) 953-7697 <br />DEPARTMENT USE ONLY <br />Application Accepted By lei Date Z <br />Grout Inspection By Date <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />Date <br />Date <br />Area� /- <br />D Employee ID# <br />J SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth <br />ft <br />PE SC Received Ch <br />Codes Info By as <br />Amount <br />Remitted Date <br />Permit/ <br />Service Request # Invoice # Well ID# <br />3 3S 37 <br />l 2 �k g <br />0 06 <br />EHEKW341604.'07:2022 Pace:nt2 W,11 PtmipPermit <br />