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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.op91ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESSV 121N.ZUCKERMAN RD AT GPS:37.987023,-121.475177(AW 4N) CITY/Zip STOCKTON,CA 95206 m <br /> CROSS STREET N.ZUCKERMAN RD APN''WA /dq©$OOq PARCEL SIZE'�4*SbCND USE APPLICATION# NA g <br /> m <br /> m <br /> OWNER NAME PACIFIC GAS&ELECTRIC PHONE y� yj y <br /> OWNER ADDRESS rO PJ O,y 7700 CITY/STATEIZIP Sqn Fforcl)sLU (7l/'D <br /> CONTRACTOR CORRPRO COMPANIES PHONE <br /> CONTRACTOR ADDRESS 2625C BARRINGTON COURT CITY/STATE/ZIP HAYWARD,CA 94545 <br /> SUBCONTRACTOR/CONSULTANT NA PHONE (510)277-5269 <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP <br /> LICENSE C-57 C-61 D-09 Other NUMBER 764878 EXPIRATION DATE 6/30/2021 <br /> BILLING PARTY: OWNERCONTRACTOR SUBCONTRACTORICONSULTANT <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/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/ModificationOthe CATHODIC PROTECTION ANODE WELL <br /> Monitoring Well(s) #of wells Soil Borings) N of bo 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 300 ft Excavation 10 in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Schad Steel Plastic Stainless Steel /Other NONE,NA <br /> Grout Seal Depth 100 ft /Neat Cement(94 Ib bag/5-10 gal water) Sand Cement sack mW7 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 NONE,NA 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 COMP LAWS. <br /> MIM/ UREQUIRED8 HO R ADVANCE NOTICE R ADVANCE NOTICE FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE PROJECT MANAGER,ENGINEER III DATE 5/21/2021 <br /> R q yM <br /> FcF��01 NT <br /> qy 2� Fo <br /> CO <br /> TVjF4 <br /> DEPARTMENT USE ONLY /µ► <br /> Application Accepted By Date 6 Area 3 �7� Employee ID# Iv• <br /> Grout Inspection By Date 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 Date Permit/ Invoice# Well ID# <br /> Codes Info B Cash Remitted Service Request <br /> 71 V2 4N�s <br /> EHD43-06 6111/2019 WELL/PUMP PERMIT <br /> 1 zS go18oS <br />