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WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)468-3420 <br /> NON-REFUNDABLE PERMIT www.sigov.org/ehd EXPIRES'I YEAR FROM DATE ISSUED <br /> B ADDRESS�%I 7"�S '-AL/1at:37.878992,Lonx:-131.331456 CITrILP French Camp/95231 6D <br /> CROSS STREET` V rCy APNt 19130018 PARCEL SIZE 81.27ac LAND USE APPLICATION# p <br /> OWNER NAME PG&E f .,t.-/ .G; V;LL0 / PHONE <br /> OWNER ADDRESS 6111 CITY/STATE/ZIP S SCIA,6 -ryA,-0/ <br /> 0 <br /> CONTRACTOR Gulf Shore Exploration PHONE 916-939-4117 <br /> CONTRACTOR ADDRESS 3362 Fitzgerald Road Cnv/STATE/ZIP Rancho Cordova,CA 95742 <br /> SUBCONTRACTOR/CONSULTANT Klcinfcldcr PHONE 209-948-1345 <br /> SUBCONTRACTOR/CONSULTANT ADDRESS 2001 Arch Airport Rd#100 CITYISTATE21P Stockton,CA 95206 <br /> LICENSE a C-57 C-61 D-09 Other NUMBER 964224 EXPIRATION DATE 8/31/2021 <br /> BILLING PARTY: OWNER CONTRACTOR X SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domesfic/Private Irrigation/Agricultural Industrial Water Quality Monitoring x 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 <br /> Monitoring Well(s) #of wells Soil Boring(s) #of borings x Geotechnical I #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 x Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Well Depth 80 ft Excavation 8 max in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth It <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad Steel Plastic Stainless Steel Other <br /> Grout Seal Depth 80 ft x Neat Cement(94 Ib bag/5.10 gal water) Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method x Pumped Free Fall x Other tremie Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width It Length ft 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 /> MINIMUM 4!8 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED_ ��✓, I TITLE President DATE 2/5/2021 <br /> YI SEN r <br /> EI VED <br /> See attached maps <br /> 112021 <br /> LQ U/N <br /> .COUNTy <br /> DEPARTMENT USE ONLY / r <br /> Application Accepted ByDate �''O l Area • � Employee ID#.-�� <br /> Grout Inspection By Date" q 'v� SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Da Permit/ Invoice# Well IN <br /> Info Cash Remitted Service Re uest# <br /> d f� <br /> EHD 63-06 6/17/2019 � 1 r/�•y ('>��/1 WELL/PUMP PERMIT <br />