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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 /> JOB ADDRESS 8401 KILTIE V CITY/ZIP Stockton / 95207 n <br /> CROSS STREET GLENCANNON ST APN 079-250-11 PARCEL SIZE400 SQ/FTLAND USE APPLICATION# <br /> rn <br /> y <br /> OWNER NAME PG&E PHONE 209-942-1421 y <br /> OWNER ADDRESS 4040 West Ln CITY/STATE/ZIP Stockton / CA / 95204 <br /> CONTRACTOR PG&E PHONE <br /> CONTRACTOR ADDRESS 535 S Center St CITY/STATE/ZIP Stockton / CA / 95203 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ■ C-57 C-61 D-09 Other NUMBER 339629 EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <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 Replacement Well Well Alteration/Modification ■ Other Anode Well <br /> Monitoring Well(s) #of wells Soil Boring(s) #of borings Geotechnical #of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Well Depth 200 it Excavation 8" in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter 2 in Thickness/Gauge/ASTM Sched Steel ■ Plastic Stainless Steel Other <br /> Grout Seal Depth 100 it Neat Cement(94 Ib bag/5-10 gal water) ■ Sand Cement 10.3 sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method ■ Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width ft Length ft Thick in Christy Box Stove Pipe <br /> PUMP Submersible Turbine ■ Other N A 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 /> INTI U 2 U NCE NOTICE REQUIRED FOR INSPECTIONS- PLEASE CALL(209) <br /> SIGNED TITLE Associate Distribution Engineer DATE 2/94 Y 1. <br /> s FEB 20 � <br /> 201 <br /> 0002 UA UIW COU <br /> I UEPARTML 11' <br /> cc KILTIE WY <br /> 0 <br /> ry <br /> ZZ PE L-f ID If 101 E Lr) <br /> f e expired v�iithnut <br /> Z ��:• eir92pieted or inspeC,A <br /> v: 0nral Rea.,, <br /> EPS R Fs11f E ONLY <br /> ��Vi ; _ <br /> Application AcceptedPyy at>? [ Area Employee ID# <br /> Grout Inspection By ramit maY halei P tp f} .... SPECIAL Well Permit <br /> Pump Inspection Byn�1 hoinn nmm�l�+n d r.r in � , -{ WAIVER Received <br /> Soil Boring Inspection By k., 97 IM4Constructed Well Depth ft <br /> COMMENTS .!11, L 1 ,.,,, <br /> U <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Cash Remitted Service Request# <br /> 4-5-41 lo. o0 �� <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4130/12 <br /> c <br />