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DC-GB 0192 <br /> 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.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRES,'L -'jS Mosswood Ave _ _ CITY/ZIP Stockton,CA.95206 m <br /> CROSS STREET Odell Ave1 J D <br /> APN 16530 V PARCEL SIZE LAND USE APPLICATION# p <br /> T <br /> OWNER NAME Pack Gas&Electric PHONE 1800-468-4743 uy, <br /> OWNER ADDRESS PO Box 997300 CITY/STATE/ZIP Sacramento,CA.95899 <br /> CONTRACTOR Gregory Drilling Inc. PHONE 425-869-2372 <br /> CONTRACTOR ADDRESS 14112 452nd Ave SE CITY/STATE/ZIP North Bend,WA 98045 <br /> SUBCONTRACTORICONSULTANT PHONE <br /> SUBCONTRACTORICONSULTANT ADDRESS CITY/STATE/ZIP <br /> LICENSE XC-57 !IC-61 D-09 II Other NUMBER 1007649 ExPIRATIONDATE 1-31-2021 <br /> BILLING PARTY: fi OWNER x CONTRACTOR 1: SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) -Arsenic(4393) <br /> INTENDED USE .7 Domestic/Private D Irrigation/Agricultural x Industrial Water Quality Monitoring D Soil Sampling/Characterization <br /> D Public Water System <br /> If different from Owner Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ❑ New Well D Replacement Well i z Well Afteration/Modification X Other Cathodic Protection <br /> Monitoring Well(s) #of wells D Soil Boring(s) #of borings I'. Geotechnical #of borings <br /> u Out-Of-Service Well D Out-Of-Service Well Renewal D Cross-Connection Repair <br /> D New Pump D Pump Replacement D Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method C Mud Rotary D Air Rotary U Auger D Cable Tool D Push Point IX Other Sonic <br /> Proposed Well Depth 49 ft Excavation 6 in diameter I Open Bottom X Gravel Pack/Gravel Size Coke in diameter <br /> '.: Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter 2 in Thickness/Gauge/ASTM Sched X Steel D Plastic i..-1 Stainless Steel 1. Other <br /> Grout Seal Depth 11 ft X Neat Cement(94 Ib bag/5-10 gal water) D Sand Cement sack mix/7 gal water <br /> I i Bentonite(20%solids) II Other <br /> Grout Placement Method X Pumped I i Free Fall D Other 11 Retardant/Accelerator(name) <br /> PEDESTAL Installed By :' Driller Pump Contractor I Other <br /> -I Concrete Pedestal Dimensions:Width ft Length ft Thick in 7 Christy Box Stove Pipe <br /> PUMP i Submersible;.11. Turbine 11 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 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-769 <br /> SIGNEDTITLE Vice President DATE 4/15/2020 <br /> EFNT <br /> IVES <br /> 2 8 ?020 <br /> E T gRTTA NTY <br /> MINT <br /> DEPARTMENT USE ONLY <br /> Application Accepted By r L!�� Date a 1 x rT 7 0 Area 5 � Employee ID# <br /> Grout Inspection By '�J �_ Data <br /> r✓`J I T./ �h7� SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Sail Boring Inspection By Date Constructed Well Depth � ft <br /> COMMENTS `L'6 � Z.,Aft f�F�J /�� I. F��� LF �`]/� T��o•s� {�J�S IyY!h) S�j� r <br /> 1 <br /> PE SC Received Che Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By Remitted SgUiceR uest# <br /> S 1 3✓S <br /> EHD43-06 6/11/2019 WELL/PUMP PERMIT <br />