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A4 <br />PA <br />SAN J� 0f1ty <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE -STOCKTON CA 95205 - (209) 468-3420 <br />N-KEFUNDA13LE PERMIT GALL <br />ADDRESS 12878 W McDonald Rd <br />STREET McDonald River Bridge APN 13102025 <br />NAME PG&E / 7�LIA <br />ADDRESS 6121 Bollinger Canyon��Zs <br />ACTOR Kleinfelder <br />ADDRESS 2001 Arch Airport Road, Suite #100 <br />FOR INSPECTIONS LXPIKtS T YEAR FROM DATE ISSUED <br />crryrzlP Stockton/ 95206 <br />PARCEL SIZE 268.95 LAND USE APPLICATION # <br />PHONE <br />PHONE (209)948-1345 <br />CITY/STATE/ZIP Stockton/ CA/ 95206 <br />IR Taher drilling PHONE (916) 371-8234 <br />IR ADDRESS 536 CalyeCtnn Street CITY/STATE/ZIP West Sacramento/ CA/ 95691 <br />C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER 969927 EXPIRATION DATE 02292020 <br />DOMESTIC WELL SAMPLING: - General Mineral/Coliform Bacteria (4391) - Dibromochloropropane (4392) -1 Arsenic (4393) <br />INTENDED USE ❑ Domestic/Private ❑ 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 ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other ' <br />❑ Monitoring Wells) #of wells ❑ Soil Boring(s) #of borings XGeotechnical 1 of borings <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />Drilling Method )Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth 50 ft Excavation 4-6 in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Schad ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth ft �II ( Neat Cement (94 Ib bag/5-10 gal wafer) ❑ Sand Cement sack mix/7 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall )(Other Tremie ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />❑ Concrete Pedestal :]Dimensions: Width ft Length It Thick in ❑ Christy Box ❑ Stove Pipe <br />PUMP ❑ Submersible E] Turbine ❑ Other 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" ')A un110 Ar%%1A\1/-1= REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED 1-tom-� TITLE Staff Geologist I DATE 3/5/2018 <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Ins action By <br />COMMENTS . L- r <br />Date <br />Date <br />�L <br />MSR � � 2018 <br />H n NM COUNTY <br />Area Employee ID#� <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth ft <br />EHD 43-06 8/01/16 n- / ,K b WELL /PUMP PERMIT <br />PE <br />SC <br />Received <br />Check#/ <br />Amount <br />Date <br />Invoice # Well ID#t <br />Permit/Codes <br />Info <br />B <br />C sh <br />Remitted <br />Service Re nest # <br />"F13 <br />EHD 43-06 8/01/16 n- / ,K b WELL /PUMP PERMIT <br />