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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 />IVVIY-RtF•UNUAtlLt rtHMIT WWWs- <br />ov.or /-h EXPIRES 1 YEAR FROM DATE ISSUE[ <br />JOB ADDRESS 1181 N Zuckerman Road <br />CITY/ZIP Stockton, CA 95206 <br />CROSS STREET Access Road APN 129-31-012 <br />PARCEL SIZE 13.51 LAND USE APPLICATION # <br />OWNER NAME Pacific Gas & Electric (PG&E) <br />PHONE <br />OWNER ADDRESS 6121 Bollinger Canyon Road <br />CITY/STATE/ZIP San Ramon CA 94583 <br />CONTRACTOR Kleinfelder <br />PHONE _ (925) 484-7032 <br />CONTRACTOR ADDRESS 6700 Koll Center Parkway, Suite 120 <br />CITY/STATE/ZIP Pleasanton CA 94566 <br />SUBCONTRACTORICONSULTANT Gulf Shore Construction Services <br />PHONE (916) 939-4117 <br />SUBCONTRACTOR/CONSULTANTADDRESS 3362 Fitzgerald Road <br />CITY/STATE21P Rancho Cordova, CA 95742 <br />LICENSE x C-57 C-61 D-09 Other <br />NUMBER 964224 EXPIRATION DATE August 31. 2021 <br />BILLING PARTY: OWNER x CONTRACTOR <br />SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring x 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 Other <br />Monitoring Well(s) # of wells Soil Borings) # of borings x Geotechnical 4 # of borings <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />'—w rum P rUTTIP me lacernent rump me air Kaise vveti ,-asin <br />WELL CONSTRUCTION <br />Drilling Method x Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br />Proposed Well Depth S�0 ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br />Grout Seal Depth 50 ft x Neat Cement (94 Ib bag75-10 gal water) Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method x Pumped Free Fall Other Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor Other <br />Concrete Pedestal Dimensions: Width ft Length It Thick in Christy Box Stove Pipe <br />PUMP Submersible Turbine Other HP Pump Set ft Standing Water Level It <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_ DJ Sullivan TITLE Staff Geologist DATE July 9, 2021 <br />N <br />g <br />0 <br />m <br />m <br />N <br />DEPARTMENT USE ONLY <br />Application Accepted By L L"ate % �a Area �fCr Employee ID#Ms <br />Grout Inspection By Date SPECIAL Well Permit <br />Pump Inspection By Date WAIVER Received <br />Soil Boring Inspection By Date Const tied Well Depth ft <br />v1MENTs 1�,/.P�..r- kl S (a7�/At? Vy _ o'AIlLi1ZIt fi►�3 Si i <br />-tn-�k l-5 tvG✓� r <br />PE <br />Codes <br />SC Received <br />InfoRemitted <br />Checlt#/ Amount Date Permit/ Invoice # Well ID# <br />ash a Request # <br />37a <br />15 <br />it <br />EHD 43-Ofi 611112019 � � �� �� � � � �� / � � WELL /PUMP PERMIT <br />