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WELL/PUMP PERMIT <br /> SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTGN AVENUE-STOCKTON CA 95205-6232(209)468-3420 <br /> NON-REFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> Jos ADDRESS 2700 West Washtingon Street crrylZlP Stockton/95203 Z <br /> CROSS STREET Navy Drive APN 145-030-110-000 PARCEL SIZE"52 ACLAND USE APPLICATION# NIA <br /> (n <br /> OWNER NAME Jet Infrastructure PHONE N/A y <br /> OWNER ADDRESS 2700 West Washington Street CITY/STATE/ZIP Stockton 195203 <br /> CONTRACTOR Middle Earth Geo Testing,Inc. PHONE 714-633-5025 <br /> CONTRACTOR ADDRESS 954 N.Leman Street CITYISTATE/ZIP Orange,CA 92867 <br /> SUBCONTRACTORICONSULTANT Wallace-Kuhl 6 Associates PHONE 916-372-1434 <br /> SUBCONTRACTOR/CONSULTANT ADDRESS 3050 Industrial Blvd. CITY/STATE/ZIP West Sacramento,CA,95691 <br /> LICENSE X C-57 C-61 0.09 Other NUMBER 899451 EXPIRATION DATE 6/30/2021 <br /> BILLING PARTY: OWNER CONTRACTOR X SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring X Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner Wale Systom Neme Contact Name or Phone Number <br /> TYPE OF WORK New Well Replacement Well Well Alteration/MGdificalion Other <br /> Monitoring Well(s) #of wells SGII Borings) #of bonngs x Geotechnical 1 w of banngs <br /> Out-0f-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement Pump Repair Raise Weil Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary Auger Cable Tool x Push Point Other <br /> Proposed Well Depth 100 It Excavation 2 In diameter Open Bottom Gravel Pack/Gravel Size N/A in diameter <br /> Conductor Casing N/A In diameter / Conductor Casing Depth N/A R <br /> Well Casing Diameter N/A in Thickness/Gauge/ASTM Sched NIA Steel Plastic Stainless Steel Other <br /> Grout Seal Depth 100 ft X Neat Cement(94 lb bag/5-10 gel water) Sand Cement sack mixl7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method ;Pumped X Free Fall X Other o-emle a water oaco,aaeed Retardant I Accelerator(name) <br /> PEDESTAL Installed By 1 Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width n Length ft Thick in Christy Box Stove Pipa <br /> PUMP SubmersibleTurbine Other HP Pump Set fl Standing Water Level Ft <br /> I HEREBY CERTIFY THAT 1 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 /> MI M 4 OU AD A CE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE Senior Engineer DATE 10/12/20 <br /> RFq yMF <br /> o cF��F T <br /> q <br /> Ro�/N ?020 <br /> H�Fpq�M�NTY <br /> HT <br /> :L=h <br /> D P RTMENT Usk ONLY /�n �^ <br /> Application Accepted ByL 1A <br /> Date I Area I ! "" mployea ID# � , V <br /> Grout Inspection By Dale SPECIAL WBII Permit <br /> Pump Inspection By Date WAIVER Received <br /> Sol(Boring Inspection By Date \o yo 1 Z3-� Constructed Well Depth It, <br /> COMMENTS fl Q,� T�n�fj�,7� b,��X V— —�v w,Q A6-CAg= AA <br /> PE Sc Received Check#/ Amount Date Permit/ Invoice# Well lo# <br /> Codas Info Q1V11 Cash RemittedService Request# <br /> 14 5L 101, I <br /> EH0 4306 61112019 q j 3q t.4- PERM <br /> WELL(PUMP IT <br /> 1 J <br />