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4� <br /> 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 /> rn <br /> JOB ADDRESS AnthonyAve&Hobart Ave CITY/ZIP Stockton,CA 95215 <br /> 1 A, D <br /> CROSS STREET Adrienne Ave APN DC-GBO1 19 /tr PARCEL SIZE LAND USE APPLICATION# O <br /> M <br /> OWNER NAME PG&E/Brigette Hernandez PHONE 916-244-3269 w <br /> OWNER ADDRESS 6121 Bollinger Canyon Road CITY/STATEIZIP San Ramon,CA 94583 <br /> CONTRACTOR Cascade Drilling LLP PHONE 916-638-1169 <br /> CONTRACTOR ADDRESS 3000 Duluth Street CITYISTATE/ZIP West Sacramento,CA 95691 <br /> SUBCONTRACTOR Barnard Pipeline PHONE 530-669-5810 <br /> SUBCONTRACTOR ADDRESS 21 Pioneer Ave. CITY/STATE/7JP Woodland CA 95776 <br /> LICENSE N C-57 D C-61 D D-09 ❑Other NUMBER 938110 EXPIRATION DATE Sept.30.2019 <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)a Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private �!IITigaflon/Agricultural X Industrial �i 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 D New Well ❑Replacement Well D Well Alteration/Modification X Other Cathodic Protection Well <br /> D Monitoring Well(s) #ofwells D Soil Borings) #ofbodngs ❑Geotechnical #of borings <br /> r.Out-Of-Service Well D Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> New Pum Pump Replacement D Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method 1 Mud Rotary D Air Rotary i Auger ❑Cable Tool ❑Push Point R Other Sonic <br /> Proposed Well Depth 200' ft Excavation 8" in diameter i Open Bottom x Gravel Pack/Gravel Size Coke Brave in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter 2e 1 Thickness/Gauge/ASTM Schad 2:SCH 40 r7 Steel Ri Plastic a Stainless Steel ElOther <br /> Grout Seal Depth�- 6 ft x Neat Cement(94/b bag/5-10 gal water) r Sand Cement sack mixf7 gal water <br /> Bentonite(20%solids) D Other <br /> Grout Placement Method X Pumped ri Free Fall X Other Pumped D Retardant/Accelerator(name) <br /> PEDESTAL Installed By 9 Driller i Pump Contractor n Other <br /> I Concrete Pedestal DDimensions:Width ft Length ft Thick in D Christy Box ❑Stove Pipe <br /> PUMP ❑Submersible Ll Turbine D Other HP Pump Set It 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 /> MINIMUM 48OUR/AD—VANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED ` ' TITLE VP Operations DATE 3/20/2019 <br /> � qy� <br /> LL <br /> oQG% 041/,9 <br /> Sou <br /> stir <br /> D A MENT UnE O LY <br /> Application Accepted By , Date v, Iq <br /> Area Employee ID# <br /> Grout Inspection By Date Z PECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth it <br /> COMMENTS <br /> PE Sc Receivedec Amount Date Permit/ Invoice# Well ID# <br /> Codes fo Remitted Service Re uest# <br /> EHD 43-06 revised 4/14/18 WELL(PUMP PERMIT <br />