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/-- <br />WELL/PUMP PERMIT /1' 3 0 — <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205-6232 (209)468-3420 <br />NON-REFUNDABLE PERMIT www.sjgov.orgtehd EXPIRES 1 YEAR FROM DATE ISSUED <br />!t) —S 7- <br />/-/Q L--= <br />CITY/STATE/ZIP <br />PHONE <br /> / <br />CITY/STATE/ZIP 14-40.06.-/Pg'r <br />PNoNe 32-_? - <br />SUBCONTRACTORICONSUL TANT ADDRESS CITY/STATE/ZIP <br />LICENSE <C-57 0 C-61 00-09 0 Other NUMBER 3 EXMRATION DATE 6-- <br /> <br />CONTRACTOR SUBCONTRACTOR/CONSULTANT BILLING PARTY: , , OWNER <br /> <br />1 <br />JOB ADDRESS /0 6 ii t7 1 Z., CirdZiP <br />CROSS STREET 47 APN 0.5 '" CI 3 PARCEL SIZE7-- # <br />OWNER NAME ge ‘Z 7 6 :,-,12-7;40 L PHONE 2. 2- .5 <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392)1 i Arsenic (43931 <br />INTENDED USE 0 Domes6dPnvate itChrigation/Agncullural 0 Industrial 0 Water Quality Monitoring 0 Sod Sampling/Characteruabon <br />Ememl Name tx Inv. Number pA . YMENT— ....... <br />Teen Or WORK a.C. New Well El Replacement Well 0 Wet Alleration/Mocitficahon 0 Other liNi-.celvd...i <br />0 Monitoring Well(s) 8 01 wells 1.) Soil Bonng(s) sot Palings 0 Geotechnical <br />0 <br />0 Out-Of-Service Well 0 Out-Of-Service Well Renewal 0 Cross-Connection Repair ---14-4R 1 0 <br />--skv•o l WELL CONSTRUCTION ENVIR QUIN COLN <br />Drilling Method 34.1A4 Rotary U Air Rotary 0 AUger 0 Cable Tool 0 Push Point Ii Other HEALINIDC)ktV4L0PA'jk. 71' <br />Proposed Welt rtwe_S tt Excavation ti in diameter 0 Open Bottom )4:Gravel Pack/Gravel Sue P .,tisterreter <br />Ii Conductx Casing in diameter I Conductor Casing Uetith <br /> <br />Well Casing Diameter 'D." in ThicknessfGauge/ASTM Sched 73Z,_D (I Sledl <br />Grout Seal Depth -.4-‘5 70(11)1 0 Neat Cement (94 5 beg)5-10 gal realer) <br />CI Bentontte (20% solids) 0 Other <br />Grout Placement MethodA.Pumped 0 Free Fall 0 Other <br />P r_SA__sTkdr atallad BY Driller Pump Contract°, n other <br />IcLump <br />0 Concrete Pedestal °Dimensions' Wtd1h4_ ft Length ft11-", LI Christy Box (1 Stove Pipe <br />Su HP /0 Pump Set <br />COORR <br /> <br />BOARD <br />;W11,44t.17.7 rTZTrLrwiTTNS"riiiieV=IP"ITOiii:11-10':1Z WORN <br />i AARLD AN <br />ffZiMY REQUIRED <br />ALSO % THAT I AM IN COMPLIANCE WITH ALL CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE <br />WORHER;Cm oOMPENSATIHON iLAWS. <br />./c- brDe rsi bl e U Turbine Othe r <br />'VANCE NOTICE REQUIRED FOR INSPECTIONS - <br />LICENSE ICE <br />pLEASE CALL (2:9) 95_3-76.y7 <br />SIGNED <br />E, <br /> <br />A S <br />III 11111 <br />111.1 IMRE <br />le <br />Francisco Garcia Ruiz, Environmental Health Asst. Page 1 of 3 <br />'J Public Water System <br />tlitterent ifOrn Owner Water Sy...T..... <br />"eNew Pump 0 Pomp Replacement Et Pump Repair El Raise Well Ca_ <br />landic sl ce IS Sleet 11 Other sa ,a6 rnaa <br /> IM <br /> wal e, <br />0 Retardant /Accelerator (name) <br />OWNER ADDRESS <br />CONTRACTOR 4i-iff entcs: <br />CONTRACTOR ADDRESS 4.?.)-/ /7 , <br />SUBCONTRACTORICONSULTANT /1: 6/2XLCr 'CH" <br />Site Address: 10696 Hwy 12, Lodi CA 95240 <br /> Record ID: WP0041776 <br />Date: 4/22/2021 <br />PHOTO # 1 New Well. Grouted from 200 ft using 10.3 sand cement.