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pc-(6 a t23 WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232 (209)468.3420 <br /> y NON-REFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> to <br /> JOB ADDRESS 10f 8 Anteros Ave C1r lZ1P Stockton,CA.95215 <br /> qq ) I r D <br /> CROSS STREET East Main St APN / !/7`J PARCEL SQE e.!a' LAND USE APPLICATION# S <br /> M <br /> OWNER NAME Pacific Gas&Electric (Cynthia Bonura) PHONE 530-488-0817 to <br /> OWNER ADDRESS 12840 Bill Clark Way CITYISTATE/ZIP Auburn,CA.95602 <br /> CONTRACTOR Gregory Drilling Inc. PHONE 425-869-2372 <br /> CONTRACTOR ADDRESS 14112 452nd Ave SE CITY/STATE/ZipNorth Bend,WA 98045 <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP <br /> LICENSE X C-57 C61 I1 "9 ❑Other NUMBER 1007649 EXPIRATION DATE 1-31-2021 <br /> BILLING PARTY: I!OWNER XCONTRACTOR SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392)L Arsenic(4393) <br /> INTENDED USE Domestic/Private i_: Irrigation/Agricultural X Industrial Water Quality Monitoring 0 Soil Sampling/Characterization <br /> I Public Water System <br /> If diflerent from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK 0 New Well [1 Replacement Well a Well Alteration/Modification X Other Cathodic Protection <br /> ❑Monitoring Well(s) #of wells 0 Soil Boring(s) #of borings 1 Geotechnical #of borings <br /> 0 Out-Of-Service Weil 0 Out-Of-Service Well Renewal Cl Cross-Connection Repair <br /> 0 New Pump U Pump Replacement 0 Pump Repair G Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary 0 Auger []Cable Tool ❑ Push Point X Other Sonic <br /> Proposed Well Depth 200 ft Excavation 8 in diameter 0 Open Bottom 0 Gravel Pack/Gravel Size in diameter <br /> 0 Conductor Casing in diameter / Conductor Casing Depth it <br /> Well Casing Diameter 2 in Thickness/Gauge/ASTM Sched X Steel ❑Plastic CI Stainless Steel rI Other <br /> Grout Seal Depth ft X Neat Cement(94 lb bag6-10 gal water) 0 Sand Cement sack mix/7 gal water <br /> i' Bentonite(20%solids) 11 Other <br /> Grout Placement Method X Pumped i-i Free Fall 0 Other L Retardant/Accelerator(name) <br /> PEDESTAL Installed By 'i Driller -1 Pump Contractor Other <br /> Concrete Pedestal[IDimenslons:Width ft Length it Thick in Christy Box Stove Pipe <br /> PUMP Submersible ' 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 /> !NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE Vice President DATE 1/12/2020 <br /> Arjo c20 <br /> H OFLIERONMOU <br /> ETry <br /> N <br /> -HPA TMENT U E ONLY <br /> Application Accepted By to / y� Area Employee ID# <br /> Grout Inspection By / Date 2 (ZG(Z ❑ SPECIAL Well Permit <br /> Pump Inspection By Date L. WAIVER Received,' <br /> Soil Boring Inspection By Date Constructed Well Depth ICI ft <br /> COMMENTS 1-Ajk�2`O." �110;a 1f�pt k-Y2 CL,.-� ,:,C—t\ i- l�— `i r C" <br /> PE SC Received Check#/ Amount Permit/ Invoice# Well ID# <br /> Codes Info a Remitted §4rvice Request# <br /> EH043-06 6/11/1019 WELL/PUMP PERMIT <br />