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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 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 />JOB ADDRESS East lane in front of 309 S. Anthony Ave_ Stockton, CA (66.22 S/O Hobart Ave.) CITY/ZIP <br />CROSS STREET Hobart Ave APN N/A PARCEL SIZE NIA LAND USE APPLICATION # <br />OWNER NAME PG&E Job# DC-GB-0119 PHONE 415-722-0842 <br />OWNER ADDRESS 6121 Bollinger Canyon Rd CITY/STATE/ZIP San Ramon CA 94583 <br />CONTRACTOR Farwest Corrosion Control PHONE 510-952-6256 <br />CONTRACTOR ADDRESS 2223 Commerce PI CITY/STATE/ZIP Hayward CA 94545 <br />SUBCONTRACTOR N/A PHONE NIA <br />SUBCONTRACTOR ADDRESS N/A CITY/STATE/ZIP N/A <br />LICENSE 1 C-57 C-61 M 0-09 Other NUMBER 248232 EXPIRATION DATE 12-31-2019 <br />DOMESTIC WELL SAMPLING: = General Mineral/Coliform Bacteria (4391)1 Dibromochloropropane (4392) = Arsenic (4393) <br />INTENDED USg ate Mrigation/Agricultural llndustrial = Water Quality Monitoring I' Soil Sampling/Characterization <br />Public Water System <br />— If different from Owner, Water System Name Contact Name or Phone Number <br />TYPE OF WORK 1 New Well = Replacement Well I Well Alteration/Modification i Other Cathodic Protection <br />El Monitoring Well(s) # of wells Epoil Boring(s) Cot borings 1 Geotechnical C ot borings <br />= Out-Of-Service Well I Out-Of-Service Well Renewal I Cross-Connection Repair <br />= New Pump I Pump Replacement I Pump Repair I Raise Well Casing A WELL CONSTRUCTION <br />Drilling Method EIVIud Rotary DAir Rotary = Auger 1 Cable Tool = Push Point III Other <br />Proposed Well Depth Z/Pi ft Excavation 10 in diameter I Open Bottom I jravel Pack/Gravel Size N/A in diameter <br />i Conductor Casing N/A in diameter / Conductor Casing Depth N/A ft <br />DEC Well Casing Diameter .in Thickness/Gauge/ASTM Sched PVC Sch 40 Steel E Plastic I Stainless Steel ElDther <br />Grout Seal Depth kW ft ININeat Cement (94 lb bag/5-10 gal water) i Sand Cement sack m Ater <br />1 Bentonite (20% solids) 1 Other <br />- ,44_47ici, Grout Placement Method i aumped Free Fall )(ther 'Ike:L " _A Retardant / Accelerator (name) <br />PEDESTAL Installed By ['Driller = Pump Contractor Li Other <br />1 i Concrete Pedestal :Dimensions: Width ft Length ft Thick in = Christy Box = Stove Pipe <br />PUMP I- Submersible= Turbine 7 Other HP Pump Set ft Standing Water Level ft <br />I HEREBY <br />JOAQUIN <br />CURRENT <br />WORKERS <br />MI <br />SIGN <br />CERTIFY THAT I HAVE PREPARED <br />COUNTY - CES, STATE <br />AND TIVE WI H THE CALIFORNIA <br />CO ENSATION AWS. <br />MUM 48 UR D <br />THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />T ER D FOR INSPECTIONS - PLEASE CALL (209) 953-7697_ . , <br />T TLE Planning Coordinator DATE 76 ,/,/-7,..2e7 <br />`.... <br />Annl iratinn Accented Rv <br />T Mr ):t NIT)IyJA E )20f; /..IY <br />Area (.2./ Ii FmnInvee nit i A 4)--4•11 <br />Inspection <br />Grout Inspection <br />Pump <br />Date <br />Date <br />SPECIAL Well Permit <br />WAIVER Received <br /> <br />Soil Boring Inspection <br />COMMENTS <br /> <br />Date <br /> <br />Constructed Well Depth <br /> <br />ft <br />XNREW <br /> <br />PE <br />Codes <br />SC <br />I to <br />Received Check#/ <br />Cash <br />Amount <br />Remitted", Date ,., Permit/ <br />,Wvice Request # Invoice # Well ID# <br />4-11( <br />lisi <br />bS/1 <br />I/ <br /> L .7"/S ID\ A 16110 a' i'l k 2 5 <br />... <br />ss-2.2-111 WELL /PUMP PERMIT END 43-06 revised 4/14118