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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 />NON-REFUNDABLE PERMIT WWW.SJgOV.01 <br />JOB ADDRESS 13k I S Byron Rd, Approx. 160' SEO Von Sosten Rd. <br />CROSS STREET Von Sosten APN IFO 20926020 <br />OWNER NAME Pacific Gas and Electric Company <br />OWNER ADDRESS 6121 Bollinger Canyon Road, <br />CONTRACTOR American Construction and Supply, Inc. <br />CONTRACTOR ADDRESS 45 San Clemente Dr., Suite A-100 <br />SUBCONTRACTOR/CONSULTANT <br />SUBCONTRACTORICONSULTANT ADDRESS <br />LICENSE ✓ C-57 C-61 D-09 Other <br />BILLING PARTY: OWNER ✓CONTRACTOR <br />a r_ArIKr_0 "I TtAK I-KOM LJAIt I55UtU <br />CITY/ZIP Tracy, Ca 95304 <br />PARCEL SIZE I' LAND USE APPLICATION # <br />PHONE 925-244-3020 <br />CITY/STATE/ZIP San Ramon, CA 94583 <br />PHONE 415-927-2024 <br />CITY/STATE/ZIP Corte Madera, Ca 94925 <br />CITY/STATE/ZIP <br />NUMBER 310599 <br />SUBCONTRACTOR/CONSULTANT <br />PHONE <br />EXPIRATION DATE 3/31/2023 <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />NTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring 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 Cathodic Protection <br />Monitoring Well(s) # of wells Soil Boring(s) # of borings Geotechnical # of borings <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />New Pump Pump Replacement Pump Repair Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method ✓ Mud Rotary / Air Rotary Auger Cable Tool Push Point Other <br />Proposed Well Deptl7,;K' 300 ft Excavation 8„ in diameter Open Bottom ✓ Gravel Pack/Gravel Size 3/8" coke in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter 2 in Thickness/Gauge/ASTM Sched 40 PVC Steel ✓ Plastic Stainless Steel Other <br />Grout Seal Depth 160';00 ft ✓ Neat Cement (94 lb bag/5-10 gal water) Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method ✓ Pumped Free Fall Other Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor Other <br />Concrete Pedestal Dimensions: Width ft Length ft Thick in Christy Box Stove Pipe <br />PUMP Submersible Turbine 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 />MINIM��M 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED ✓' TITLE Steve McKim, Vice President DATE September 21, 2021 <br />DEPARTMENT USE ONLY <br />Application Accepted By �r^_�7 /--L Date /1 D 7 .Z 7 <br />Grout Inspection By 'Str ( u- Date - <br />Pump Inspection By Date <br />Soil Boring Inspection By Date <br />COMMENTS 1LD 6f we b l r, t .-rD m --P <br />Area b 9 / Employee ID# <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth ft <br />PE <br />Codes <br />Sc Received Check#/ <br />Info By. Ca h <br />Amount Permit/ <br />Remitted Date Service Re nest # Invoice # Well ID# <br />y3'7i <br />181 <br />EHD43-06 6/11/2019 /•, /' WELL /PUMP PERMIT <br />