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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 />N-KEFUND LE PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />ADDRESS^' N. ZUCKERMAN RD AT GPS: 37.987156,-121.473203 CITYZP STOCKTON, CA 95206 <br />Ss STREET N. ZUCKERMAN RD APN NA 101q O8P1l) O9 PARCEL SIZE'!!!!9T-AND USE APPLICATION # NA <br />NAME PACIFIC GAS <br />& ELEC <br />TRIC <br />ADDRESS P0 Igo)(/ -I VyTI <br />O O <br />ICTOR CORRPRO COMPANIES <br />CONTRACTOR ADDRESS 2625C BARRINGTON COURT <br />SUBCONTRACTORICONSULTANT ADDRESS <br />LICENSE CED C-61 <br />BILLING PARTY: OWNER <br />D-09 Other <br />PHONEt' <br />CITY/STATE/ZIP� /C�mjl(I u D <br />PHONE <br />CrrvISTATEZP HAYWARD, CA 94545 <br />CITYISTATE/ZIP. <br />NUMBER 764876 <br />SUBCONTRACTORICONSULTANT <br />PHONE (510)277-5269 <br />ExPIRATION DATE 6/30/2021 <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 frwn Owner. Water System Name Contact Name or Phone Number <br />TYPE OF WORK New Well Replacement Well Well Alteration/Modification Othe CATHODIC PROTECTION ANODE WELL <br />Monitoring Well(s) # of wells Soil Borings) If Of Geotechnical a 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 />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 it <br />Well Casing Diameter_ in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel / Other NONE, NA <br />Grout Seal Depth 100 it / 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 Pumped Free Fall Other Retardant / Accelerator (name) <br />PEDESTAL Installed By / Driller Pump Contractor Other <br />Concrete Pedestal Dimensions: Width K Length It Thick in Christy Box Stove Pipe <br />PUMP Submersible Turbine /Other NONE, NA HP Pump Set it Standing Water Level it <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 COMPPW LAWS. <br />MI 1 X38 HO R ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED TITLE PROJECT MANAGER, ENGINEER III DATE 5/21/2021 <br />DEPARTMENT USE NLY n <br />Application Accepted By Date O� a I Area `/ C Employee ID# <br />NA <br />Grout Inspection By , r 5Z� Date SPECIAL Well Permit <br />Pump Inspection By Date WAIVER Received <br />Soil Boring Inspection By Date Constructed Weii Depth ft <br />COMMENTS <br />PE SC Received <br />Codes Info <br />Check#/ Amount Date Permltl Invoice # Well ID# <br />Cash Remitted Service Request # <br />3 <br />so—, 4.5 <br />EHD 43-06 6f11I2019 i/ J�V O A WELL (PUMP PERMIT <br />MFN�, <br />0 <br />2021 <br />.o �Nry <br />