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wpfm5o4s WELL/PUMP PERMIT SAN JOA;ZUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS 1i5O WeS'y 1 1 T wne, Po,, CITY/ZIP Lodi r t59'y' m CROSS STREET O0.Ar�S APN 0 a1c\ o� 003 PARCEL SIZ �6 LAND USE APPLICATION# A OWNER NAME `-r`-�(/1�'y�/��y y�I%Alm rAA'%71 GS L L c— PHONE N OWNER ADDRESS I l7 Q�Qj G \ CITY/STATE/ZIP /A 1/ CONTRACTOR NO 0 Avwler5 �o, � 't�©e-l''`ljfs CTerracp"� PHONE to-3-701 CONTRACTOR ADDRESSDj IV\L1A -F � / SUBCONTRACTOR ccme_ PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP {{ LICENSE C-57 C-61 LI D-09 F1 Other NUMBER WAg2! EXPIRATION DATE I J�I(CI DOMESTIC WELL SAMPLING: [i General Mineral/Coliform Bacteria(4391)a Dibromochloropropane(4392)❑Arsenic(4393) INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural I:1 Industrial ❑ Water Quality Monitoring Soil Sampling/Characterization ❑ Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings Geotechnical #of borings ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair I I New Pump I I Pump Replacement ❑ Pump Repair I I Raise Well Casing WELL CONSTRUCTION Drilling Method ❑ Mud Rotary I I Air Rotary )(Auger I_I Cable Tool Li Push Point I I Other Proposed Well Depth 5 ft Excavation 6 in diameter I I Open Bottom ❑ Gravel Pack/Gravel Size in diameter ❑ Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel I Plastic I I Stainless Steel I 1 Other Grout Seal Depth ft g Neat Cement(94 Ib bag/5-10 gal water) 1 Sand Cement sack mix/7 gal water ❑ Bentonite(20%solids) I 1 Other Grout Placement Method fl Pumped LI Free Fall I I Other ❑ Retardant/Accelerator(name) PEDESTAL Installed By I I Driller 1] Pump Contractor I I Other ❑ Concrete Pedestal Ll Dimensions:Width ft Length ft Thick in [I Christy Box ❑ Stove Pipe PUMP Submersible I Turbine I I Other HP Pump Set ft Standing Water Level ft I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MINIMU 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL(209) 953-7697 SIGNED TITLE Jen, ,C � y �f�� DATE NY n y Q r �-<k AN AQP EP RTMENT USE ONLY Application Accepted By Date ZL5A c-11 Area Employee ID#� Grout Inspection By Date I I SPE IAL Well Permit Pump Inspection By Date l WAIVER Received Soil Boring Inspection By ` ;C'�LL Date 91281 Constructed Well Depth ft COMMENTS PE Sc Received eck#/ Amount Date Permit/ Invoice# Well ID# Codes Info By Remitted Service Request# EHD 43-06 8/01/16 WELL/PUMP PERMIT