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WELL �RERRJMI <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)468-3420 <br /> NON-REFUNDABLE PE MIT 54 L TMsigov.or hd EXPIRES 1 YEAR FROM DATE ISSUED <br /> SO / �CITY/ZIP <br /> JOB ADDRESS .a LI iI <br /> CROSS STREET Alleki APN_'^ 1�� /( -• O <br /> 7 T_ 7 ARCEL IZE S LAND USE APPUCATO A <br /> M <br /> OWNER NAME PHONE <br /> OWNER ADDRESS / �C/ � � CRY/STATE/LP <br /> CONTRACTOR PI ONE <br /> CONTRACTOR ADDRESS CRY/STATEMP <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITYISTATEMil--- <br /> LICENSE C-57 C-61 D-09 Other NUMBER EXPIRATION DATE <br /> BILLING PARTY: OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391)t Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE ' C omestic/Pnvate 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 New Well L Replacement Well L Well Alteration/Modification Other <br /> Monitoring Wells) #of wells n Soil Boring(s) #of borings Geotechnical #of borings <br /> Out-Of-Service Well D Out-Of-Service Well Renewal Cross-Connection Repair <br /> l New Pump Pump Replacement D Pump Repair Raise Well Casing <br /> LCONSTRUCTION <br /> Drilling Method -toted-Ro_ta_ry Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Well Depth _Tt Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in er / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/AST Steel _ Plastic Stainless Steel Other <br /> �� �/J�J !/ Grout Seal Depth ft Neat Cement(94 lb bag15-10 ga Sand Cement sack mix/7 gal water <br /> (/L� Bentonite(20%solids) Other <br /> 1� Grout Placement Method Pumped Free Fall Other Retardant/Accelerato e) <br /> ( PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width ft Length ft Thick in Christy Box ' Stove Pipe <br /> PUMP 7-Submersible Turbine Other HP Pump Set It Standing Water Level <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. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE ITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPEN N LAWS. <br /> MIN 48 HOUR DVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(2019),195/, 9 <br /> SIGN TRLE_ �Cft.� DATE <br /> 46 <br /> E ANT <br /> AWT- <br /> 3 2021 <br /> EIV Q'i ENTU�N <br /> T Ty <br /> A/R ENT <br /> DEPARTMENT USE ONLY f, <br /> Application Accepted By e Lid Date 3 a I Area � � / Employee ID# A <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By C Date S[}r ' 2:" L I WAIVER Received <br /> Soil Boring Inspffction By Date Constructed Well Depth ft <br /> COMMENTS VNe��` i 9s1t } iJ PBO.39gy5 <br /> PE SC Received Che Amount Date Permit/ Invoice# Well ID# <br /> Codes Info Remitted Service Re u <br /> '1396 :0 3-23'2 <br /> EH043-06 6/1112019 WELL/PUMP PERMIT <br />