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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.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />fJOB ADDRESS 16775 S Howland Rd CITY/ZIP Lathrop, CA 95330 <br />CROSS STREET E Louise Ave APN 19814004 PARCEL SIZE 8 • 76 LAND USE APPLICATION# <br />OWNER NAME PG&E <br />OWNER ADDRESS 61.11 Bollinger Canyon Road <br />CONTRACTOR ConeTec <br />CONTRACTOR ADDRESS <br />820 Aladdin Ave <br />PHONE <br />CITY/STATEIZIP San Ramon, <br />CA 94583 <br />PHONE 510-357-3677 <br />CITYISTATEIZIP San Leandro, CA 94577 <br />SUBCONTRACTOR/CONSULTANT Kleinfelder PHONE 661-302-2054 <br />SUBCONTRACTOR/CONSULTANT ADDRESS 2001 Arch Airport Rd, Suite 100 CITYISTAI/TTE/�ZIPufStockton, CA 95206 <br />LICENSE /C-57 C-61 D-09 Other NUMBER _I 0A j,�- 1 EXPIRATION DATE <br />BILLING PARTY: OWNER CONTRACTOR UBCONTRACTORICONSULTANT <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/Characteri <br />zation <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) 2 # of borings Geotechnical # of borings <br />Out-Of-Servioe Well Out -Of -Service Well Renewal Crass -Connection Repair <br />New Pumn PumD Renlacement Pumn Renair Raise Well Casino <br />WELL CONSTRUCTION <br />Received <br />Check#I <br />Cast <br />Amount <br />emitted <br />Ott <br />Drilling Method <br />Mud Rotary Air Rotary Auger <br />Cable Tool Push <br />Point <br />Other CPT (direct push) <br />Proposed Well <br />Depth 80 ft Excavation 2 <br />in diameter <br />Open Bottom Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter I <br />Conductor Casing Depth <br />ft <br />Well Casing <br />Diameter in Thickness/Gauge/ASTM Sched <br />Steel <br />Plastic Stainless Steel Other <br />Grout Seal <br />_ <br />Depth 8 0 ft Aleat Cement (94 <br />lb bag/5-10 gal water) <br />Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method Pumped Free Fall Other <br />tr emi a <br />Retardant / Accelerator (name) <br />PEDESTAL <br />Installed By Driller Pump Contractor <br />Other <br />Concrete Pedestal Dimensions: Width <br />ft Length <br />ft <br />Thick in Christy Box Stove Pipe <br />PUMP <br />Submersible Turbine Other <br />HP <br />Pump <br />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 />MINIMU 4 HOU ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED Io-g.t'� TITLE Calif. Manager DATE 12-21-20 <br />DEPARTMENT USE ONLY <br />Application Accepted By ��'�'� Date /�? d Q a aZQ <br />Grout Inspection By Date <br />Pump Inspection By Date <br />Soil Boring Inspection By Date 5 Za'Z� <br />COMMENTS <br />Area � IC" ��OP Employee ID# U/1 <br />SPECIAL W211 Permlt <br />WAIVER Received <br />Constructed Well Depth ft <br />T <br />D <br />O <br />A <br />m <br />N <br />F� M�Nl <br />�EO <br />PE SC <br />Codes Info <br />�y3i,�� )so <br />HD43-06 <br />Received <br />Check#I <br />Cast <br />Amount <br />emitted <br />Ott <br />Date <br />Permit] <br />is Re uest <br />Invoice # <br />Well ID# <br />611112019 WELL (PUMP PERMIT <br />