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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 Ln <br /> !JOB ADDRESS 15300E Sargent Rd CITY21P Lodi, CA 95240 m <br /> E. of Tull Rd. 053-070-08 i 18.81 D <br /> CROSS STREET y APN PARCEL SIZE LAND USE APPLICATION# <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. CITY/STATEIZIP Modesto, CA 95356 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/LP <br /> LICENSE C-57 L C-61 ❑ D-09 r-� Other NUMBER <br /> 290813 EXPIRATION DATE 5-31-24 <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE ❑ Domestic/Private i,. Irrigation/Agricultural 0 Industrial ❑ Water Quality Monitoring C Soil Sampling/Characterization <br /> ❑ Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK XNew Well L� Replacement Well ❑ Well Alteration/Modification r; Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings i7 Geotechnical #of borings <br /> ❑ Out-Of-Service Well 0 Out-Of-Service Well Renewal L Cross-Connection Repair <br /> =i New Pump D Pump Replacement 0 Pump Repair 0 Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method IX Mud Rotary 0 Air Rotary Ci Auger ❑ Cable Tool 0 Push Point ❑ Other <br /> Proposed Well Depth 466 ft Excavation 22 in diameter :ii Open Bottom 0 Gravel Pack/Gravel Size rl in diameter <br /> X Conductor Casing in diameter / Conductor Casing Depth 50 ft <br /> Well Casing Diameter _ in Thickness/Gauge/ASTM Sched SDR21 0 Steel Xl Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth ) ft 0 Neat Cement(94 Ib bag/5-10 gal water) A Sand Cement 10 -3 sack mix17 gal water <br /> Bentonite(20%solids) �§ Other conductor casing cemented-in with 2 parts sand and 1 part cement <br /> Grout Placement Method :.1:Pumped ❑ Free Fall 0 Other 0 Retardant/Accelerator(name) <br /> PEDESTAL Installed By D Driller ;qPump Contractor D. Other <br /> Concrete Pedestal[I Dimensions:Width ft Length ft Thick <br /> in Christy Box Stove Pipe <br /> PUMP C Submersible0 Turbine 0 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 /> MINl�tU�t 24 HOUR ADVANCE NOTIC-. PECI'IO k9E CALL(209)4r <br /> D ART MENT USE ONLY <br /> Application Aco—nted�) Date 11/3/2022 Area 4/99 Employee]D# F. Glrar i <br /> Grout Inspection By Date 0 SPECIAL W@II Permit <br /> Pump Inspection By Date 0 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received Check#/ Amount Date PermlU Invoice# Well ID# <br /> Codes Info B Cash Remitted Service Request# <br /> —4369 180 420 <br /> F�I <br /> EIID049-05 101252021 Pagc tar'- Ncll/Pump I'cnnit <br />