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+ C-1753 WELL/PUMP PERMIT <br />T SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />NUN-KEFUNDABLE VERMIT 1www.S <br />OV.or /ena <br />tArIKCJ I T tAK rKVM UA I t IbbUtu <br />JOB ADDRESS 23300 Kennefick Rd <br />—eI <br />CITYIZIP <br />Acampo, CA 95220 <br />CROSS STREET Fairlane RD APN <br />ROW <br />PARCEL SIZE <br />LAND USE APPLICATION # <br />OWNER NAME PG&E <br />PHONE <br />OWNER ADDRESS 3965 Occidental Road Q <br />/ <br />( <br />CITY/STATE/ZIP <br />Santa Rosa, CA 95401 <br />CONTRACTOR Gregory Drilling <br />PHONE 530-565-6289 <br />CONTRACTOR ADDRESS 14112 452nd Ave SE <br />CITY/STATE/ZIP <br />North Bend, WA 98045 <br />SUBCONTRACTORICONSULTANT Barnard Construction <br />PHONE 406-586-1995 <br />SUBCONTRACTORICONSULTANT ADDRESS 701 Gold Ave <br />CITY/STATE/ZIP <br />Bozeman, MT 59715 <br />LICENSE X C-57 C-61 D-09 Other <br />NUMBER 1007649 <br />EXPIRATION DATE 1-31-23 <br />BILLING PARTY: '.I OWNER XCONTRACTOR <br />SUBCONTRACTORICONSULTANT <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) '�. i Arsenic (4393) <br />NTENDED 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 X Other Cathodic Protection <br />Monitoring Well(s) # of wells Soil Boring(s) u of borings Geotechnical u of bonnge <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />noise vven <br />Drilling Method Mud Rotary I Air Rotary i Auger Cable Tool i Push Point X Other Sonic <br />Proposed Well Depth 58 ft Excavation in diameter i Open Bottom X Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft Calcined Coke Breeze <br />Well Casing Diameter 2 in Thickness/Gauge/ASTM Schad 40 Steel X Plastic Stainless Steel Other <br />Grout Seal Depth 20 ft X Neat Cement (94 lb bag/5-10 gal wafer) Sand Cement sack mixrl gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method X Pumped - Free Fall I Other Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller - Pump Contractor X Other Barnard Construction <br />Concrete Pedestal _Dimensions: Width ft Length It Thick in X 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 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />-.v <br />SIGNED y —`2 ---��� TITLE President DATE 5-24-21 <br />DA MENT U E O N L Y <br />Application Accepted By4*jDate <br />i <br />Grout Inspection By i ! Dale /IA <br />Pump Inspection By Date <br />Soil Boring Inspection By Date <br />COMMENTS <br />Area Employee ID#;r `WA(ril/r 2 <br />SPECIA Well Permit <br />WAIVER Received <br />Constructed Well Depth ft <br />KsurM►�i�:��ii���r��iF437 �nnl�li�i�ir�� <br />EHD 43-06 6/112019 4W 4 WELL /PUMP PERMIT <br />EHD 43-06 6/112019 4W 4 WELL /PUMP PERMIT <br />