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1868 EAST HAZELTON AVENUE -STOCKTON CA 95205 -6232 (209)468-3420 <br />www.sjgov.orgiehd EXPIRES 1 YEAR FROM DATE ISSUED <br />L1211 C1 9/? cirazip <br />APN 0550-7 oa PARCEL SIZE 6., LAND USE APPLICATION # <br />PHo EGR0q4d 3 <br />JOB ADDRESS <br />CROSS STREET <br />OWNER NAME <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />NON-REFUNDABLE RMIT <br />OWNER ADDRESS <br />CONTRACTOR <br />la() wilco( Pizei <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br /> kDA\ <br />PHONE e-g-0?e:B/ etWn <br />CITY/STATE/ZIP 6/W1M (60k3 q5-cws-- <br />PHONE <br />C STATE/ZIP <br />CONTRACTOR ADDRESS <br />SUBCONTRACTOR/CONSULTANT <br /> <br />omestic./Private 0 Irrigation/Agricultural 0 Industrial 0 Water Quality Monitoring 0 Soil Sampling/Characterization <br />0 Public Water System <br /> <br />Water System Name Contact Name or Phone Number <br />INTENDED USE <br />If different from Owner <br />Gravel Pack/Gravel Size in diameter <br />ft <br />WELL CONSTRUCTION <br />Drilling Method 0 Mud Rotary 0 Air Rotary 0 Auger 0 Cable Tool 0 Push Point 0 Other <br />Proposed Well Depth ft Excavation in diameter 0 Open Bottom <br /> <br />0 Conductor Casing in diameter / Conductor Casing Depth <br />in 0 Christy Box 0 Stove Pipe ft Thick <br />Submersible 0 Turbine 0 Other HP / Pump Set .3-: ft Standing Water Level ei ft Ky <br />THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />SIGNED <br />I HEREBY CERTI <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 />I&D NCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953/697/ <br />TITLE ,le"We DATE Z 3/ 779 <br />Installed By 0 Driller 0 Pump Contractor 0 Other <br />El Concrete Pedestal ODimensions: Width ft Length <br />PEDESTAL <br />PUMP <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched 0 Steel O Plastic 0 Stainless Steel 0 Other <br />Grout Seal Depth ft C Neat Cement (94 lb bag/5-10 gal water) 0 Sand Cement sack mix/7 gal water <br />0 Bentonite (20% solids) 0 Other <br />Grout Placement Method U Pumped 0 Free Fall 0 Other 0 Retardant / Accelerator (name) :S93LICICIV 311S PA <br />/ten -"Qifir <br />FEB 0 <br />Sovoi j,„ 2021 _ <br />HeilirpOivilAC7).UNry <br />EPAR7.4;447. <br />rpf:_ LlicKhrvi <br />a ,m11.• qoot) <br />Application Accepted By <br />Grout Inspection By <br />DEPARTMENT USE ONLY <br />Date d/3/02 ) <br />Date r <br />Pump Inspection By fr6 C (C1 r at-4 Date 1( ft Ei <br />END 43-06 6/11/2019 WELL /PUMP PERMIT <br /> <br />q/66 F 12 Area / i Employee ID# <br />0 SPECIAL Well Permit <br />0 WAIVER Received <br />Soil Boring Inspection By Data Constructed Well Depth ft <br />COMMENTS <br />PE <br />Codes <br />SC <br />Into <br />Received <br />:1/4,7-) <br />Checac#4 <br />„ <br />Amount <br />Remitted <br />Permit/ <br />ServiAe Request #4•-% Invoice # Well ID# <br />H3g1 a S ° W- ‘01 — .70..c--/ *77 <br />Ditei. li <br />6 I tAlF00141(011) <br />WELL/PUMP PERMIT <br />LICENSE C-57 0 C-61 0 D-09 <br /> 0 Other NUMBER EXPIRATION DATE <br />BILLING PA : 0 OWNER <br /> CONTRACTOR SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: 0 General Mineral/Coliform Bacteria (4391) CI Dibromochloropropane (4392) C Arsenic (4393) <br />TYPE OF WORK CI New Well 0 Replacement Well 0 Well Alteration/Modification 0 Other <br />0 Monitoring Well(s) # of wells 0 Soil Boring(s) # of borings 0 Geotechnical # of borings <br />0 Out-Of-Service lll 0 Out-Of-Service Well Renewal 0 Cross-Connection Repair <br />0 New Pump Pump Replacement 0 Pump Repair 0 Raise Well Casing