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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1688 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468.3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> N <br /> Joe ADDRESS [620N,(37.623531,-121.391648)] cl-lLP lacy,CA 95377 m <br /> CROSS STREET 1-580 APN 2650600520121- D <br /> PARCEL SIZE LAND USE APPLICATION# 0 <br /> OWNER NAME San Francisco Public Utilities Commission PHONE 415-551-3000 <br /> OWNER ADDRESS 525 Golden Gate Avenue CITyISTATE/21P San Francisco,CA 94102 <br /> CONTRACTOR HEW Drilling <br /> PHONE 650-322-2851 <br /> CONTRACTOR ADDRESS 1045 Weeks Street CITY/STATElZJP East Palo Alto,CA 94303 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STArE0P <br /> LICENSE x C-57 I:.C-61 r D-09 ii Other NUMBER 604987 EXPIRATION DATE 10/31/2020 <br /> DOMESTIC WELL SAMPLING: _General MineraVColiform Bacteria(4391)f Dibromochloropropane(4392);.-1 Arsenic(4393) <br /> INTENDED USE -Domestic/Pttvate Irrigation/Agrlcunurai Industrial I I Water Quality Monitoring X Soil Sampling/Charactenzation <br /> L Public Water System <br /> If etaerem hom Owner: Water System Name Collect Name or Phone Number <br /> TYPE OF WORK t-.New Well Replacement Well -Well AlteratforifModification Other <br /> Monitoring Well(s) 9 of wets .Sod Boring(s) ►of bones ,5t Geotechnical 2 9 of borings <br /> 3 Out-Of-Service Well -.Out-Of-Service,Well Renewal a Cross-Conneclion Repair <br /> New Pump Pump Replacement ,.,PuM2 Repair Raise Well Casi <br /> WELL CONSTRUCTION <br /> Drilling Method _ Mud Rotary Air Rotary X Auger Cable Tool Push Point j Other <br /> Proposed Well Depth 50 tt Excavation up to 8 in.in diameter I Open Bottom I Gravel Pack/Gravel Size in diameter <br /> U Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad t Steel _Plastic L Stainless Steel L'.Other <br /> Grout Seal Depth 54 ft )4 Neat Cement(94/b bag/5-10 gal water) L Sand Cement sack mix!]gal water <br /> 1 Bentonite(20%solids) C Other <br /> Grout Placement Method X Pumped :1 Free Fan I Other -1 Retardant/Accelerator(name) <br /> PEDESTAL Installed By i!Driller -Pump Contractor Other <br /> .I Concrete Pedestal L'Dlmensions:Width ft Length tt Thick in Christy Box Stove Pipe <br /> lum Submersiblei!Turbine r Other HP Pump Set ft Standing Water Level tt <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUINcCOUNTY ORDINANCES, STATE 4AWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CUR RENT-AND-AeRVE WITH THE CALIF NW CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORCOM NSA'IbN LAWS. <br /> 1 I 1 1i TALL( 09 953-7697 <br /> �. / 'PLEASE C 2 <br /> SIONED� �,.^-_ r) �...� TITLE �4L� 1.4t: DA'r <br /> -�o � <br /> - T <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Area Employee ID# <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 Checkillf Amount Date Perm1U <br /> Codes Info B Cash Remitted Service Request 9 invoice# Well ID# <br /> 21ID 43-M revbed 4114118 <br /> WELL/PUMP PERMIT <br />