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WELL/PUMP PERMIT <br />SAN JOADUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN -REFUNDABLE HERMIT UALL ('LUB) ySJ-Itis / FOR INSPECTIONS tAHIKtS T YEAR FROM I ISSUES <br />Joe ADDRESS on East side of North F St (115 if south off Waterloo Rd.) ( CITY/ZIP Stockton, 95205 <br />CROSS STREET Waterloo Rd APN.101-' <br />ARCEL SIZE LAND USE APPLICATION # <br />OWNER NAME county right ofway PHONE 2091168-3420 <br />ADDRESS CITY/STATEIZIP <br />,CTOR Fanvesl Corroslon Control "All Work Is Done For PG&E PM# 313732361DC-GS-0005 PHONE 510-925-6256 <br />CTOR ADDRESS 2223 Commerce Place CITY/STATE/ZIP Hayward CA 94545 <br />ACTOR <br />SUBCONTRACTOR ADDRESS _ <br />LICENSE ❑✓ C-57 ❑ C-61 <br />CITY/STATEIZJP, <br />NUMBER 248232 <br />PHONE <br />EXPIRATION DATE 17131!2019 <br />DOMESTIC WELL SAMPLING: L General Mineral/Coliform Bacteria (4391) D Dibromochloropropane (4392) a Arsenic (4393) <br />INTENDED USE ✓ DomesliGPrivate �t--�Im,gation/Agricultural nduslrial Lt Water Quality Monitoring ❑ Soil Sampling/Characterization <br />Public Water Sysle'1� <br />IfdBerent from Owner: Wotor, System Noma Contact Name or Phone Number <br />TYPE OF WORK V/ New Well 11Replacement Well G Well Alteration/Modification ✓ Other Cathodic Protection <br />D Monitoring Well(s) # of wells Soil Boring(s) # or borings = Geotechnical # of Wnngs <br />Out -Of -Service Wel( D Out -Of -Service Well Renewal D Cross -Connection Repair <br />New Pump ❑ Pump Replacement D Pump Repair ❑ Raise Well Casing <br />A <br />PERM" o" cepted By <br />Jaction <br />By <br />lion By <br />pX <br />pl[]WI&4tion By <br />M E N T U O L Y <br />.Dale Area Employee ID# <br />Dale ❑ SPECIAL WDII Permit <br />Date ❑ WAIVER Received <br />Date Constructed Well Depth ft <br />N <br />m <br />D <br />A <br />N <br />PE SC Received Check#/ Amou Date Permit/ Invoice # Well ID# <br />Codes Info By Cash Remitted Service Re est# <br />i <br />Drilling Method Q ud Rotary D4ir Rotary h Auger F Cable Tool (' Push Point F1 Other <br />Proposed Well Depth 201 It Excavation 10 in diameter rl Open Bottom ravel Pack/Gravel Size Na in diameter <br />I Conductor Casing n/a in diameter / Conductor Casing De th nla It <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched S. Steel D Plastic --: Stainless Steel Ther <br />Grout Seal Depth 100 It QNeal Cement (94 lb bagl5-10gal water) D Sand Cement sack mixf7 gal water <br />7 Bentonite (20% solids) r, Other <br />Grout Placement MethodEl-umped L Free Fall - Other _. Retardant / Accelerator (name) <br />PEDESTAL Installed By ElDriller 2 Pump Contractor L—,'J Other W-1 <br />❑ Concrete Pedestal EDimenslons: Width R Length ft Thick in C Christy Box ❑ Stove Pipe <br />i <br />PUlAP .1 Submersible C Turbine C Other HP Pump Sel ft Standing Water Level ft <br />I HEREBY CERTIFY THAT IHAS PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAQUIN COUNTY ORDINAES, TATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE W , H TH CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATI N LAW . <br />MIN MUM H ADV N OijICE EQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED Planning Coordinator DATE 12-18-2018 <br />Ail <br />W <br />A <br />PERM" o" cepted By <br />Jaction <br />By <br />lion By <br />pX <br />pl[]WI&4tion By <br />M E N T U O L Y <br />.Dale Area Employee ID# <br />Dale ❑ SPECIAL WDII Permit <br />Date ❑ WAIVER Received <br />Date Constructed Well Depth ft <br />N <br />m <br />D <br />A <br />N <br />PE SC Received Check#/ Amou Date Permit/ Invoice # Well ID# <br />Codes Info By Cash Remitted Service Re est# <br />i <br />EHD 43-06 rchsed 4114/18 WELL RUMP PERMIT <br />