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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 />NVN-KEFUNDABLE PERMIT www.$)gov.org/ena tAI'IKtb 9 TEAR FROM DATE ISSUED <br />JOB ADDRESS 27007 Hansen Rd <br />CITymp Tracy/95377 <br />CROSS STREET I — 5 8 0 APN 251-320-14 <br />PARCEL SIZE 170 LAND USE APPLICATION # <br />OWNER NAME PG&E/ Chacopulos, Patricia <br />PHONE <br />OWNERADDRESS 7700 College Town Dr <br />CITYISTATE/ZIP Sacramento/ 95826 <br />CONTRACTOR Kleinfelder <br />PHONE 209-469-4312 <br />�l <br />CONTRACTOR ADDRESS 2001 Arch Airport Rd #100 <br />CITY/STATE/ZIP Stockton/CA/95206 <br />SUBCONTRACTORICONSULTANT Taber Drilling <br />PHONE 916-371-8234 <br />SUBCONTRACTOR/CONSULTANTADDRESS 536 Galveston St <br />CITYISTATE/ZIP West Sacramento/CA/95691 <br />LICENSE / C-57 i� C-61 0 D-09 D Other <br />NUMBER 969927 EXPIRATION DATE 2/ 2 9/ 2 0 2 0 <br />BILLING PARTY: LJ OWNER /CONTRACTOR LJ SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: n General Mineral/Coliform Bacteria (4391) CI Dibromochloropropane (4392) 11 Arsenic (4393) <br />INTENDED USE 7i Domestic/Private D Irrigation/Agricultural D Industrial D Water Quality Monitoring y( Soil Sampling/Characterization <br />i 1 Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK I i New Well D Replacement Well I I Well Alteration/Modification D Other <br />L' Monitoring Well(s) # of wells n Soil Boring(s) # of borings Geotechnical 3 n of borings <br />U Out -Of -Service Well D Out -Of -Service Well Renewal I t Cross -Connection Repair <br />Drilling Method XMud Rotary D Air Rotary XAuger j Cable Tool r Push Point Other <br />Proposed Well Depth 4 0 ft Excavation 8 in diameter . Open Bottom r Gravel Pack/Gravel Size in diameter <br />-i Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Schad Steel Plastic D Stainless Steel - Other <br />Grout Seal Depth 4 0 ft e Neat Cement (94 lb bag15-10 gal water) Sand Cement sack mixf7 gal water <br />Bentonite (20% solids) - Other <br />Grout Placement Method Pumped _ Free Fall 1i Other Tremi a i_ Retardant / Accelerator (name) <br />PEDESTAL Installed By - Driller Pump Contractor Other <br />I Concrete Pedestal Dimensions: Width ft Length ft Thick in D Christy Box C Stove Pipe <br />PUMP ❑ Submersible Turbine Lj 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 />SIGNED 'Vkle, r- 't -0ti TITLE staff engineer DATE 11/27/2019 <br />See Attached Map. <br />DEPARTMENT USE ONLY <br />Application Accepted By Date Area Employee ID# <br />Grout Inspection By Date 1 SPECIAL Well Permit <br />Pump Inspection By Date 1 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 Re uest# <br />EHD 43-06 6/112019 WELL /PUMP PERMIT <br />r� <br />D <br />A <br />m <br />w <br />