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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 /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Jos ADDRESS Puckermen Rd 1 Neugerbauer Rd �Z/2 1!L 4-W,/6K f CrryfbP Stockton,CA 95206 to <br /> CROs STREETZudkemlan RD 1 Neugerbauer RC APN 129 OS 009 PARCEL S(ZE 565 aae9LAND USE APPLJCATION# <br /> 0 <br /> OWNER NAME PG&E <br /> PHONE 800-743.50D0 tNr <br /> OWNER ADDRESS 2121 Zuckerman Rd CITYISTATE/ZIP Stockton.CA 95206 <br /> CONTRACTOR Corrpro Companies PHONE 510-614-8800 <br /> CONTRACTOR ADDRESS 20991 Calot Blvd CrrY/STATEIZIP Hayward,CA 94545 <br /> SUBCONTRACTOR NONE PHONE <br /> SUBCONTRACTOR ADDRESS CmISTATEMP – <br /> LICENSE 3 C-57 C C-61 0 D-09 D Other NUMBER Z§yZ8 EXPIRATION DATE 6-30-2019 <br /> DOMESTIC WELL SAMPUNG:„General Mineral/Coliform Bacteria(4391)n Dibromochloropropane(4392)L Arsenic(4393) <br /> LIthodic <br /> TENDED USE :3Domestic(Private 0 Inigation/Agricultural 0 Industrial C Water Quality Monitoring 0 SON Sampling/Characterization <br /> 0 Public Water System <br /> Protection It ditrent from Oester: Water Syetem Name Cagan Name or Phone Nurnim <br /> TYPE OF WORK )t New Well ❑Replacement WSJ U Well Aeeration/Modification 0 Other Cathodic Protection t BOnng <br /> 0 Monitoring Wel(S)__#of wells O Soil Borings) a a bore- U Geotechnical s of borings <br /> D Out-Of.Servlce Well 0 Out-0f-Service Wel Renewal 0 Cross-Connection Repair <br /> J New Pump 0 Pump Re lacernent C Pump Repair 0 Raise Well Casino <br /> WELL CONSTRUCTION <br /> Drilling Method LXMud Rotary ❑Air Rotary 0 Auger n Cable Tool a Push Point D Other <br /> Proposed Well Depth 251 ft Excavation t0 in diameter C Open Bottom C Gravel Peck/Gravel Sze— in diameter <br /> 0 Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in ThicknesWGauge/ASTM Schell U Steel G Plastic ❑Stainless Steel 0 Other <br /> Grout Seal Depth 100 ft LX Neat Cement(941b bag15-10 gal water) 0 Sand Cement sack mull gal water <br /> C Bentonite(20%Solids) C Other <br /> Grout Placement Method (X Pumped ,)Free Fan U Other C Retardant I Accelerator(name) <br /> PEDESTAL Installed By D Driller 0 Pump Contractor i Other <br /> U Concrete Pedestal ODImenslons:Width ft Length ft Thick In 0 Christy Box t7 Stove Pipe <br /> P C Submersible a Turbine U Other HP Pump Set it Standing Water Level ft <br /> 1 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. 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 /> MINIMUM 48 HOUR A4,a( QLNOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> St"EcPaulBostwick --•a'~"`�"'" "` Operations Manager <br /> TITLE DATE <br /> I LL <br /> Q <br /> EPA TMENT LIFE ONLY <br /> Application Accepted By Date (7 I AreaEmployee ID# <br /> Grout Inspection By Date 0 1AL Well Permit <br /> Pump Inspection BY Date ❑ WAIVER Received <br /> Solt Boring Irypedtion By Date Construe Wal!Dept n <br /> CO ENT'$ f 7cfi 4�6P G�Gl�AtN <br /> PE SC Recehred Check#/ Amount Permit/ <br /> Codes Into Clash Remitted Data ServicePAclupato Invoice# Well ID# <br /> END 4306 nrAW4H4n8 <br /> WELL)PUMP PERMIT <br />