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1 C-1891 WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN-KEFUNDABLE PERMIT GALL ZU9 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 50 S Eugenia ST & E Anderson yle(41- 1700 ffi 1 }ole CITY/ZIP Stockton CA 95205 <br />CROSS STREET Milton St <br />OWNER NAME PG&E <br />APNne61I 1 SS ��v PARCEL SIZE • 1 LAND USE APPLICATION # <br />PHONE 408-313-0963 <br />OWNER ADDRESS 3136 Boeing Way CITY/STATE/ZIP Stockton, CA 95206 <br />CONTRACTOR Gregory Drilling, Inc PHONE 530-565-6289 <br />CONTRACTOR ADDRESS 14112 452nd Ave Se CITY/STATE/ZIP North Bend, WA 98045 <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE X C-57 <br />C-61 D-09 Other <br />PHONE <br />CITY/STATE/ZIP <br />NUMBER 1007649 EXPIRATION DATE <br />1-31-23 <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE Domestic/Private Irrigation/Agricultural X 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 X New Well Replacement Well Well Alteration/Modification X Other Cathodic Protection <br />Monitoring Well(s) # of wells Soil Boring(s) # of borings Geotechnical # o C <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 S <br />O <br />Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point X Other Sonic E I 20? <br />Proposed Well Depth 110' ft Excavation in diameter Open Bottom x Gravel Pack/Gravel Size 0 <br />Conductor Casing in diameter / Conductor Casing Depth ft " Backfill 50'-1 10' with Ze <br />Well Casing Diameter 2 in Thickness/Gauge/ASTM Sched 40 Steel x Plastic Stainless Steel Other FN <br />Grout Seal Depth 50 ft x 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 x Pumped Free Fall Other Retardant / Accelerator (name) <br />)EDESTAL Installed By Driller Pump Contractor x Other Barnard Pipeline <br />Concrete Pedestal Dimensions: Width ft Length ft Thick <br />n x Christy Box Stove Pipe <br />PUMP Submersible Turbine Other HP Pump Set ft Standing Water Level ft <br />Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect to the following items: GPS <br />Coordinates, property lines, adjoining properties, water bodies or courses, drainage pattern, roads, existing wells, structures, <br />potential sources of contamination, sewers or private disposal systems. Include distance from two property lines. For Domestic, <br />Agriculture, Industrial well, provide location of any water wells or surface water within 200' radius of proposed well. <br />N11NINIUN1 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />DEPARTMENT USE ONLY f /� <br />Application Accepted By — L L Date S-12� oZ.2 Area S7J�kfa� Employee ID# " "S <br />Grout Inspection By %N� Date • Z.3 X22- SPECIAL Well Permit <br />Pump Inspection By Date WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />fn <br />1 <br />m <br />D <br />v <br />v <br />m <br />rn <br />(7- <br />PE <br />r <br />PE SC Received Check#/ <br />Codes Info By,% Cash <br />Amount ate Permit/ Invoice # Well ID# <br />Remitted P Service Request # <br />371 <br />S- 2 P e <br />EHDO43-06 10/25/2021 4'Page I ort Well / Pump Pcrn it <br />/TI) 3� <br />