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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY <br /> ��E VIRO�,y�t�nENTAL HEALTH DEPARTMENT 1 B58 EAST HAZELTON AVENUE-STOCKTON CA 95285-(289)468-3420 <br /> NON- AW'E IOIYi CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> 75 S.Lammers Rd. c N <br /> JOB ADDRE/ LaCITV/ZIP Tracy 95377 <br /> D <br /> CROSS STREET —2780'S/0 Valpico Rd. APN EO 25105003 PARCEL SIZE LAND USE APPLICATION# o <br /> A <br /> OWNER NAME Pacific Gas and Electric Company PHONE 925 244-3806 N <br /> OWNER ADDRESS 6121 Bollinger Canyon Rd CITYISTATE/ZJP San Ramon,CA 94583 <br /> CONTRACTOR American Construction and Supply, Inc PHONE 415 927-2024 <br /> CONTRACTOR ADDRESS 45 San Clemente Dr.I Ste A-100 CITY/STATEIZIP Corte Madera,CA 94925 <br /> SUBCONTRACTOR N/A PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ✓C-57 C-61 D-09 Other NUMBER 310599 EXPIRATIONDATE 03/31/2019 <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domeshc/Pnvate Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characlenzation <br /> Public Water System <br /> II different from Owner Wator System Namc C-1-1 Neme or Phone Number <br /> TYPE OF WORK ✓New lAlell Replacement Well Well Alteration/Modifica[ion ✓Other Cathodic Protection <br /> Monitoring Wells} #of wells Soil Boring(s) #afbonngs Geotechnical of nm�yls <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pum ___Pump Replacement Pump Repair _Raise Well Casing <br /> WELL CONSTRUCTION <br /> �pT Drilling Method ✓Mud Rotary Air Rotary Auger Cable Tool Push Point Other kI� <br /> Proposed Well Depth 300 ft Excavation 10 in diameter Open Bottom �GrdKRh r 'e tiek�)se in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter 2 in Thickness/Gauge/ASTM Sched 40 Steel ✓Plastic Stainless Steel Other <br /> Grout Seal Depth 100 It Neal Cement(941b bag/5-10 ga!uvater) ✓Sand Cement 10.3 sack mfxl7 gat water <br /> Bentonite(20%solids) Other - <br /> Grout Placement Method ✓Pumped Free Fall Other Retardant I Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> NIA Concrete Pedestal Dimensions.Width ft Length It Thick in Christy Box Stove Pipe <br /> PUMP N/A Submersible Turbine Other HP Pump Set It Standing Water Level ft <br /> I HEREBY CERTIFY THAT I HAVE P EPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCE TATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WIT -E CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATI AWS. <br /> MINIh1U 3' ANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGN Steve McKim TITLE Vice President DATE 05/22!2018 <br /> [' s I e 1 3 JE _ z r JI E D <br /> 23 ,70, <br /> F Q 7N <br /> MR�C <br /> �Nry <br /> NT <br /> P A TMENT U E O Y <br /> Atlhi <br /> Application Accepted By Date Area Employee ID#Apvto <br /> Grout Inspection By Date (o SPECIAL Well Permit <br /> Pump Inspection By Dale WAIVER Received rn' <br /> Soil Boring Inspection By Date Cons7cted Well Depth ' ft <br /> COMMENTS <br /> UPPO <br /> PE SC Received Check#I Amount Permit/ <br /> e <br /> Codes Into BY— Cash RDatInvoice# Well ID# <br /> X^ 4) <br /> emitted Service Re uest# Q <br /> EVD nl-o5 revised anar+e � � <br /> !/uX WELL.. PERMIT <br />