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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 /> JOB ADDRESS 15300E Sargent Rd CITY/ZIP Lodi, CA 95240 m <br /> E. of Tully Rd. 053-070-08 118.81 D <br /> CROSS STREET APN PARCEL SIZE LAND USE APPLICATION# z <br /> M <br /> OWNER NAME Sargent Estates LLC PHONE 650-867-7784 <br /> OWNER ADDRESS 15300 E. Sargent Rd. CITY/STATE/ZIP Lodi, CA 95240 <br /> CONTRACTOR Hennings Bros. Drilling Co., Inc. PHONE 209-545-1185 <br /> CONTRACTOR ADDRESS 3525 Ladd Rd. CITYISTATE/ZIP Modesto, CA 95356 <br /> SUBCONTRACTOR PHONE <br /> 'SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C-57 ❑ C-61 ❑ D-09 rl Other NUMBER EXPIRATION DATE 5-31-24 <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private 0 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 /> TYPE OF WORK LT New Well ❑ Replacement Well _ Well Alteration/Modification C' Other <br /> ❑ Monitoring Well(s) #of wells ' Soil Boring(s) X of borings ❑ Geotechnical K of borings <br /> ❑ Out-Of-Service Well _; Out-Of-Service Well Renewal L Cross-Connection Repair <br /> ❑ New Pump D Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method X Mud Rotary ❑ Air Rotary ! Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth 400 ft Excavation in diameter D Open Bottom ❑ Gravel Pack/Gravel Size i in diameter <br /> X Conductor Casing ' { in diameter / Conductor Casing Depth 50 ft <br /> Well Casing Diameter 12 in Thickness/Gauge/ASTM Sched SDR21 ❑ Steel X Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth 50 ft ❑ Neat Cement(94 lb baq/5-10 gal water) ;(Sand Cement I s sack mix17 gal water <br /> ❑ Bentonite(20%solids) X other conductor casing cemented-in with 2 parts sand and 1 part cement <br /> Grout Placement Method (XPumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller X Pump Contractor ❑ Other <br /> C Concrete Pedestal❑Dimensions:Width ft Length ft Thick <br /> in ❑ 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 /> MllVIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> DEPARTMENT USE ONLY <br /> ApplicationAca9nt(!gI � Date 11/3/2022 Area 4/99 Employee ID# F. G I ra ric I <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes I Info By Cash Remitted Service Request# <br /> 180 420 <br /> EIID043--0h 10/75/7021 1'agc I nrI Wdl/P—P Pcmrir <br />