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ENIVIRONMNIAL <br />HEALTH DEPARTMENT <br />END 43-06 6(1112019 <br />Area Employee 10/1 <br />SPECIAL Well Permit <br />WAIVER Received <br />ft Constructed Well Depth <br />1108 <br />WELL/PUMP PERMIT <br />Watei Systerri N81 no Contact Name or Phone Number <br />DOMESTIC WELL SAMPLING: 1 General Mineral/Conform Bacteria (4391) 1 Dibromochloropropane (4392) -I Arsenic (4393) <br />Well Alteration/Modification Other <br />- Soil Boring(s) # -,t i-,fir js 11 Geotechnical A ot borings <br />Out-Of-Service Well Renewal Cross-Connection Repair <br />_I Pump Repair Raise Well Casing <br />TYPE OF WORK I New Well I Replacement Well <br />i Monitoring Well(s) <br />, Out-Of-Servrce Well <br />I New Pump x Pump Replacement <br />ft of wells <br />NUMBER 1055434 EXPIRATION DATE 7/31/2021 <br />BILLING PARTY: I I SUBCONTRACTOR/CONSULTANT OWNER CONTRACTOR <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />NON-REFUNDABLE PERMIT <br />JOB ADDRESS 14341 N. Beckman Rd. <br />1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209)468-3420 <br />WWW.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />CITY/ZIP Lodi/95240 <br />CROSS STREET Kettleman Ln. APN 061-02-008 <br />OWNER NAME <br />OWNER ADDRESS <br />CONTRACTOR <br />CONTRACTOR ADDRESS 646 S. California St. <br />S UBCONTRACTOR/C ONSULTANT <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />LICENSE I C-57 X C-61 D-09 Other <br />PARCEL SIZE 6.32 LAND USE APPLICATION # <br />PHONE 209-607-4956 <br /> CITY/STATE/ZIP Ls q5-20 <br />PHONE 209-466-9625 <br />crryisTATErzo Stockton CA, 95203 <br />PHONE <br />CITY/STATE/ZIP <br />California Islamic Cemetery <br />SAME Po Q,L# <br />Delta Pump. Inc. <br />INTENDED USE Domestic/Private X Irrigation/Agricultural Industrial 7 Water Quality Monitoring r Soil Sampling/Characterization <br />, Public Water System <br />di'fer,.1._ <br />U Cable Tool _ Push Point _ Other <br />in diameter <br />WELL CONSTRUCTION <br />Drilling Method _. Mud Rotary L Air Rotary U Auger <br />Proposed Well Depth ft Excavation <br />_I Conductor Casing in diameter <br />in diameter I Open Bottom :1 Gravel Pack/Gravel Size <br />I Conductor Casing Depth ft <br />Grout Placement Method _ Pumped I Free Fall _ Other Retardant!I. Accelerator (name) <br />ft Thick <br />PEDESTAL <br />in Christy Box 1 1 Stove Pipe <br />Installed By Driller Pump Contractor Other <br />-I Concrete Pedestal ilDimensions Width ft I ength <br />Well Casing Diameter in ThicknessiGauge/ASTM Sched I Steel <br />Grout Seal Depth ft _ Neat Cement (94 lb bag/5- 10 gat water) <br />i Bentonite 120% solids) L Other <br />Plastic i Stainless Steel <br />_ Sand Cement sack rnix!7 gal water <br />Other <br />X Submersible_ Turbine Other Pump Set ft Standing Water Level PUMP HP ft <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS. AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />TM CEO DATE 11/20/2020 <br />gftifftiaifts <br />M EN , ONLY <br /> <br />Application Accepted By ____.‘7-0.-2 1-- Date /3/0cV? C 20 <br /> <br />Grout Inspection By Date <br /> <br />Pump Inspection By Dale rlA ( t(141k <br /> <br />Soil Boring Inspection By Date <br />COMMENTS <br />PE <br />Codes <br />SC <br />Info <br />Received <br />B <br />Checktt/ <br />Cash <br />Amount <br />Remitted Date Permit/ <br />Service Request if Invoice N PAYMENT <br />ECEIVED Li KO OSO <br />/ 22- G L( 477 <br />t..; . <br />III- 11.)i0 I Ajc(ii' 4-I Ci- <br />DC 1 0 2020 <br />Ml <br />SIGNED <br />*.! rr-s. SS3dClaV 311S