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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 />NUN -REFUNDABLE PERMIT <br />JOB ADDRESS 7477 Kile Road <br />CROSS STREET Kile Road / Private A@ <br />OWNER NAME Den Hartog Farms <br />OWNER ADDRESS 7497 Kile Road <br />CONTRACTOR <br />L;ALL ZUy 95J-11591 FOR INSPECTIONS LAVIRt, l TEAR FROM DATE ISSUED <br />CITY/ZIP Lodi / 95242 <br />Road APN 00126010 PARCEL SIZE 150 aC LAND USE APPLICATION # <br />PHONE 209-224-7412 <br />CITY/STATE/ZIP Lodi / CA / 95242 <br />v � i <br />CONTRACTOR ADDRESS <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE X C-57 NA C-61 ❑ D-09 ❑ Other <br />PHONE A) � <br />CITY/STATE/ZIP 1 1 <br />PHONE <br />CITY/STATE/ZIP <br />NUMBER AS ^%6 r EXPIRATION DATE <br />DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) ❑ Arsenic (4393) <br />INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ 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 C New Well ❑ Replacement Well ❑ Well Alteration/Modification X Other Verify existing pump installation <br />- Monitoring Well(s) # of wells El Soil Boring(s) <br /># of borings ❑ Geotechnical # of borings <br />C Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />-i New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION RECEIVED <br />Drilling Method ❑ Mud Rotary 11 Air Rotary ❑ Auger ❑ Cable Tool 11 Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size )clifflr <br />Conductor Casing in diameter / Conductor Casing Depth ft r '-- <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Oth r <br />Grout Seal Depth ft ❑ Neat Cement (94 Ib bag/5-10 gal water) F1 Sand Cement S r <br />El Bentonite (20% solids) ❑ Other ueer TH- —DE RA17TIu11 lJ <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />❑ Concrete Pedestal I_IDimensions: Width ft Length ft Thick <br />�in ❑ Christy Box ❑ Stove Pipe <br />PUMP X Submersible[] Turbine ❑ Other HP 5 Pump Set + - 90 ft Standing Water Level +1--2-0-- 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 />MINIMUM 24 IIOUR ADVANCE: NOTICE, REQUIRE.[) FOR INSPECTIONS - PLEASE' (:ALL (209) 953-7697 <br />DEPARTMENT USE ONLY CJ <br />Application Accepted By ''—� Date 9.// 7b Area I �( Employee ID#IJA <br />Grout Inspection By 4 Date ❑ SPECIAL Well Permit <br />Pump Inspection By Date 22&zl- ❑ WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS NPvJ t,,Q61 I Qn,r u,^)+-- s 9 0c).? I yb 0 <br />0 <br />to <br />m <br />m <br />D <br />0 <br />0 <br />m <br />m <br />rn <br />to <br />PE SC Received / <br />Codes Info Py Cash <br />Amount Permit! <br />Date Invoice # Well ID# <br />Remitted Service Request # <br />438 os) 13 0 o <br />se 22 <br />q cl <br />EHD043-06 10/25/2021 Pugc I oC 2 Well / Pump Permit <br />