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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232 (209)468-3420 <br /> NON-REFUNDABLE PERMIT www.siaov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 2121 N Zuckerman Rd cITY/zIP Stockton/95206 <br /> m <br /> D <br /> CROSS STREET W Mcdonal d Rd APN 12908009 PARCEL SIZE 5 6 5 LAND USE APPLICATION# o <br /> m <br /> m <br /> OWNER NAME PG&E PHONE <br /> OWNER ADDRESS 2121 N Zuckerman Rd/Alffi(s( 1T0—X0d-TY/STATE/7JP Stockton/CA/95206 <br /> CONTRACTOR Taber Drilling PHONE (916) 371-8234 <br /> CONTRACTOR ADDRESS 536 Galveston St CITY/STATEZP West Sac/CA/95691 <br /> SUBCONTRACTOR/CONSULTANT Kleinfelder PHONE (209) 948-1345 <br /> SUBCONTRACTORICONSULTANTADDRESs 2001 Arch Airport Rd CITY/STATE/ZIP Stockton/CA/952D6 <br /> LICENSE //�'57 1 C-61 Fl D-09 FI Other NUMBER� 7EXPIRATION DATE <br /> BILLING PARTY: OWNER 11 CONTRACTOR BCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria 4391) Dibromochloropropane(4392) 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 -i Replacement Well u Well Alteration/Modification a Other <br /> Monitoring Well(s) #of wells i7 Soil Boring(s) #of bodngs XGeolechnical 4 #of borings <br /> Out-Of-Service Well f,Out-Of-Service Well Renewal C Cross-Connection Repair <br /> New Pum - Pump Replacement C Pump Repair J Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method)<Mud Rotary C Air Rotary 1=i Auger C Cable Tool C Push Point - Other <br /> Proposed Well Depth 50-80 ft Excavation 6 in diameter L Open Bottom L Gravel Pack/Gravel Size in diameter <br /> -Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched ' Steel _1 Plastic _1 Stainless Steel ':i Other <br /> Grout Seal Depth It A Neat Cement(94 lb bag/5-10 gal water) ❑Sand Cement sack mix/7 gal water <br /> - Bentonite(20%solids) i Other <br /> Grout Placement Method x Pumped a Free Fall Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller L�Pump Contractor El Other <br /> Concrete Pedestal El Dimensions:Width ft Length ft Thick in -]-Christy Box i_I Stove Pipe <br /> PUMP _ Submersible_1 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 /> M�UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE VP/Exploration Coordinator DATE 11.12.2019 <br /> pgY41 <br /> 10 A <br /> I C1 <br /> FcFo��r <br /> y O <br /> Qvl, ?019 <br /> !24N <br /> F q�COU NAY <br /> NT <br /> A MENT USE NLY <br /> Application Accepted By ate Area `L' Employee ID#, <br /> Grout Inspection By Date SPECIA Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By '44- Date?/ 2 Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Perm!V Invoice# Well ID# <br /> Codes Info Bv Ca§h Remitted Service Request# <br /> LAY C'Ie�.,-�' I � .- d <br /> EHD43-06 6/112019 _ / �����q n/,�� ���('7���eT WELL]PUMP PERMrr <br />