Laserfiche WebLink
WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />IVVIV-I-IEFUNOABLE ll- MIT I;ALL lUy Ub3-lby! FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS, 135 COTTAGE AVE <br />CITY/ZIP <br />7 MAiJl <br />CROSS STREET YOSEMITE AVE APN 223-430-02 <br />PARCEL SIZE 9 OCfeS <br />LAND USE APPLICATION # <br />Invoice # <br />OWNER NAME PG&E <br />PHONE 209-942-1421 <br />OWNER ADDRESS 4040 West Ln <br />CITY/STATE/ZIP <br />Stockton / CA / 95204 <br />CONTRACTOR PG&E <br />PHONE <br />CONTRACTOR ADDRESS 535 S Center St <br />CITY/STATE/ZIP <br />Stockton / CA / 95203 <br />SUBCONTRACTOR <br />PHONE <br />SUBCONTRACTOR ADDRESS <br />CITY/STATE/ZIP <br />LICENSE ■ C-57 C-61 D-09 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 />Ir <br />Public Water System <br />It different from Owner: Water bystem Name contactName or Phone um er <br />'YPF OF WORK ■ Naw Wall RP.nIACP.mant Wall Wall Altaratinn/Mnriificatinn ■ nthar Anode Well <br />Monitoring Well(s) # of wells Soil Boring(s) # of borings Geotechnical <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br /># of borings <br />New Pump Hump Heplacernent Pump Hepalr Raise Well 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 T 'ckness/Gauge/ASTM Sched Steel ■ Plastic Stainless Steel Other <br />Grout Seal Depth f5t" fi 1 Neat Cement (94 Ib bag15-10 gal water) ■ Sand Cement 10.3 sack mix17 gal water <br />Bentonite (20% ,lid,) Other <br />Grout Placement Method ■ Pumped Free Fall Other 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 1 AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />MINI <br />n"110 VANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED TITLE Associate Distribution Engineer DATE 6/22/2017 <br />Q PARTMENT SE ONLY ���Sj <br />Application Accepted B _ Date Area Employee ID# 6 U <br />Grout Inspection By lK ,— �' Date �� �y�t— SPECIAL Well Permit <br />Pump Inspection By Date WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS 1,01 t LvI �t+l�c� /Y'�ii' /� j S4!�e , <br />PE <br />Codes <br />Sc Received <br />Info B <br />Ch ! . C <br />ash m <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # <br />Well ID# <br />v3dAl <br />EHD43-06 WELL PUMP PERMIT <br />413012 <br />