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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN -REFUNDABLE PERMIT (;ALL (ZUV) y53 -/by! FOR INSPECTIONS hAPIHhb 1 YEAR FROM UATE ISSUED <br />(Q_ <br />JOB ADDRESS 15661 CURRY AVE. CITY/ZIP LODI / 95242 <br />FT VINEY <br />CROSS STREET KETTLEMAN LN. APN IN FRONT OF 049-230-01 PARCEL SIZEt LAND USE RDll�APPLICATION # <br />OWNER NAME PG&E �L K O PHONE 209-932-6461 <br />OWNER ADDRESS 4040 West Ln CITY/STATE/ZIP Stockton / CA / 95204 <br />CONTRACTOR PG&E PHONE <br />CONTRACTOR ADDRESS 535 S Center St CITY/STATE/ZIP Stockton <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE ■ C-57 C-61 D-09 <br />PHONE <br />CA / 95203 <br />CITY/STATE/ZIP -7 <br />Other NUMBER 339629 EXPIRATION DATE <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br />NTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System <br />If different from Owner: Water bystern Name Go-niact Name or Phone Number <br />TYPE OF WORK ■ New Well Replacement Well Well Alteration/Modification ■ Other Anode Well <br />Monitoring Well(s) # of wells Soil Boring(s) #of borings Geotechnical a of borings <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />iNew rump rump hepiacemem rump mepair masse vven casing <br />WELL CONSTRUCTION <br />Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br />Proposed Well Depth 200 ft Excavation 8" in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter 2 in Thickness/Gauge/ASTM Sched Steel ■ Plastic Stainless Steel Other <br />Grout Seal Depth 25 ft Neat Cement (94 /b bag/5-10 gal water) ■ Sand Cement 10.3 sack mW7 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method ■Pumped Free Fall Other o.—i c4-- Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor Other <br />Concrete Pedestal Dimensions: Width ft Length ft Thick in Christy Box Stove Pipe <br />PUMP Submersible Turbine ■ Other N A HP Pump Set ft Standing Water Level ft <br />I HEREBY CERTIFY THAT I 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 />MINIM M 2 OU ANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED TITLE Associate Distribution Engineer DATE 7/01/2016 <br />#15661 - <br />-agw expo <br />cDmogted or 1n p <br />� iA00���nta1 <br />by �� <br />KETTLEMAN c <br />Z <br />y <br />5' <br />q <br />DEPARTMENT <br />Application Accepted By >/ .1-LcJ_� <br />n-/� Date <br />USE <br />� <br />TT llV <br />Grout Inspection By <br />Date <br />Amount <br />Remitted <br />Pump Inspection By <br />Date <br />Invoice # <br />Soil Boring Inspection By <br />Date <br />COMMENTS <br />0 <br />ZW <br />�W <br />aW <br />11 <br />Area 04 l( Employee ID# <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth ft <br />cn <br />a <br />D <br />0 <br />0 <br />M <br />M <br />cn <br />PE <br />Codes <br />SC <br />Info <br />Received <br />B <br />Cheek#/- <br />L Cm <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # <br />Well ID# <br />EHD 43-06 WELL /PUMP PERMIT <br />4/3012 <br />