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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232 (209)468-3420 <br /> NON-REFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 1399 E.Turner Road CITY17JP Lodi,CA 95240 ti <br /> m <br /> CROSS STREET N.Guild Avenue APN 044F33-023 PARCEL SIZE 5.18 aCC O <br /> LAND USE APPLICATION# O <br /> A <br /> OWNER NAME AGI En ineerin -Contact:Alex Innes F7jjC1j4b&0 PHONE 209.939.9900 <br /> OWNER ADDRESS 1325 EI Pinal Drive,Unit 7 ZI CITY/STATE/ZIP Stockton CA 95205 <br /> CONTRACTOR V&W Drilling-Contact:Karli Stroing PHONE 209.981.7755 <br /> CONTRACTOR ADDRESS 1133 Blackhurst Drive CITY/STATE/ZIPGalt,CA 95632 <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP <br /> LICENSE X C-57 C-61 D-09 Other NUMBER 720904 EXPIRATION DATE 04/30/2020 <br /> BILLING PARTY: OWNER CONTRACTOR - SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391)FE Dibromochloropropane(4392)r:1 Arsenic(4393) <br /> INTENDED USE Domestic/Private Irrigation/Agricultural -industrial C 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 0 New Well 1 1 Replacement Well C Well Alteration/Modification C Other <br /> 0 Monitoring Weil(s) #of wells ❑Soil Boring(s) #ofborings XGeotechnical 3 #of borings <br /> ❑Out-Of-Service Well C Out-Of-Service Well Renewal Cross-Connection Repair <br /> 11 New Pum '_:Pump Replacement C Pump Repair G Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method C Mud Rotary Air Rotary X Auger ;Cable Tool D Push Point ❑ Other <br /> Proposed Well Depth 10-25 ft Excavation 4 1/2 in diameter C Open Bottom D Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth It <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched 0 Steel D Plastic C Stainless Steel IOther <br /> Grout Seal Depth full depth ft X Neat Cement(94 Ib bag/5-10 gal water) ❑Sand Cement sack rri gal water <br /> Bentonite(20%solids) II Other <br /> Grout Placement Method Pumped D Free Fall X Other Tremie ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller '::Pump Contractor Other <br /> Concrete Pedestal ODimenslons:Width ft Length ft Thick in ❑Christy Box 1.Stove Pipe <br /> PUMP Submersible Turbine Other HP Pump Set ft Standing Water Level 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 /> '�/Iyp• M HOUR �•p/7EQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED l / TITLE Project Coordinator DATE 01/03/2020 <br /> pAY�SNT <br /> 6I 8A <br /> ��i <br /> OAQUIN COUNTY NTy <br /> M DEPARrM#NT <br /> Ha <br /> EP RTM ENT SE ONLY �t� <br /> Application Accepted By ate Area Vv Employee ID#Ix-E-�-'�r— <br /> Grout Inspection By Date PECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By ( PA_li J7_� Date = > ���t•7 Constructed Well Depth k <br /> COMMENTS <br /> PE SC Received her Amount Permit/ <br /> C Info B sh Ijemi#ed Date Se ice Re uest# Invoice# Well ID# <br /> Vi ir,W. <br /> O <br /> EHD 4306 6/11QO19 WELL/PUMP PERMIT <br />