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1 WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> N <br /> JOB ADDRESS 15300E Sargent Rd. __ CITYIZIP Lodi, CA 95240 <br /> of Tull. _ 053-070-08 118.81 D <br /> CROSS STREET Ey RdAPN PARCEL SIZE LAND USE APPLICATION# A <br /> m <br /> OWNER NAME Sargent Estates LLC PHONE 650-867-7784 N <br /> OWNER ADDRESS 15300 E. Sargent Rd. CITYISTATE/ZJP Lodi, CA 95240 <br /> CONTRACTOR Hennings Bros. Drilling Co., Inc. PHONE 209-545-1185 <br /> CONTRACTOR ADDRESS 3525 Ladd Rd. CITYISTATE17JP Modesto, CA 95356 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE X C-57 ❑ C-61 D D-09 n Other NUMBER 290813 EXPIRATION DATE 5-31-24 <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE ❑ Domestic/Private X Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Sol Sampling/Characterization <br /> ❑ Public Water System PA I— <br /> If different from Owner. Water System Name Contact Name or Phone Number iz <br /> TYPE OF WORK X New Well ❑ Replacement Well D Well Alteration/Modfication ❑ Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #or/�Ilr�,ps O <br /> D Out-Of-Service Well G Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> ❑ New Pum ❑ Pump Replacement ❑ Pum Repair ❑ Raise Well Casing 'S4 At In <br /> 0320, <br /> WELL CONSTRUCTION NFq�T IRON IN CO <br /> Drilling Method X Mud Rotary ❑ Air Rotary ❑ Auger 11Cable Tool ❑ Push Point ❑ Other H MFN Ty <br /> Proposed Well Depth 400 ft Excavation 22 in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size no. 6 in 1 <br /> X Conductor Casing 24 in diameter / Conductor Casing Depth 50 ft <br /> Well Casing Diameter 12 in Thickness/Gauge/ASTM Sched SDR21 ❑ Steel X Plastic D Stainless Steel D Other <br /> Grout Seal Depth 50 ft ❑ Neat Cement(94 Ib bag/5-10 gal water) p{Sand Cement 10•_3 sack mix/7 gal water <br /> ❑ Bentonite(20%solids) 6 Other conductor casing cemented-in with 2 parts sand and 1 part cement <br /> Grout Placement Method d(Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller X Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal❑Dimensions:Width ft Length ft Thick <br /> lin ❑ Christy Box ❑ Stove Pipe <br /> PUMP ❑ Submersible[] Turbine ❑ 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 /> st1�I\IUrt 24 110 LAZA D AN I N0IR P,REQ!,IRE <br /> D ARTMENT USE ONLY <br /> Area 4/99 Employee F. Glrar <br /> Application A' Date 11/3/2022 I <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date �1 Constru ted I.D p h ft <br /> COMMENTS 7 / <br /> PE SC Received hec Amount Permitl. <br /> Codes Info B _7 Cash Remitted Date Service Request# Invoice# Well ID# <br /> 4 69 180 420 <br /> ElID043-06 10252021 Page i ore %veil/P=V Pttma <br />