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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 /> N <br /> JOB ADDRESS W Oak St & Alice Ave (Near APN 001-190-67) CITY/ZIP Thornton / 95686 m <br /> CROSS STREET Alice Ave APN SJC Right of Way Y PARCEL SIZE LAND USE APPLICATION# M <br /> M <br /> OWNER NAME PG&E PHONE 209-942-1421 <br /> OWNER ADDRESS 4040 West Ln CITY/STATE/ZIP Stockton / CA / 95204 <br /> CONTRACTOR PG&E PHONE <br /> CONTRACTOR ADDRESS 535 S Center St CITY/STATE/ZIP Stockton / CA / 95203 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ■ C-57 C-61 D-09 Other NUMBER 339629 EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: water System Name Uontact Name or Phone Number <br /> TYPE 0 WORK ■ New Well Replacement Well Well Alteration/Modification ■ Other Anode Well IPA YAAI:Ak <br /> Monitoring Well(s) #of wells Soil Boring(s) #of borings Geotechnical -nE <br /> If V <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair ^ O <br /> New Pum Pum Replacement Pum Repair Raise Well CasingAPR <br /> WELL CONSTRUCTION <br /> jj <br /> Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other AEJOAQ- C <br /> Proposed Well Depth 200 ft Excavation 8" in diameter Open Bottom Gravel Pack/Grave N <br /> D t Uometer <br /> Conductor Casing in diameter / Conductor Casing Depth ft iew <br /> Well Casing Diameter 2 in Thickness/Gauge/ASTM Sched Steel ■ Plastic Stainless Steel Other <br /> Grout Seal Depth 50 ft Neat Cement(94 lb bag/5-10 gal water) ■ Sand Cement 10.3 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 N A HP Pump Set it 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. 1 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 /> MINIMU 24 ODVANCE NOTICE REQUIRED FOR INSPECTIONS- PLEASE CALL (209)953 7697 <br /> SIGNED TITLE Associate Distribution Engineer DATE <br /> PERiMIT E',", L� <br /> Nq mit may have expired withnut <br /> r:o, i being completed er inspec'.-d PROPOSED WELL <br /> DW <br /> by =iiv:ronmer! a1 Hem i; Division • <br /> 5f— <br /> W <br /> Q <br /> W OAK ST w <br /> U_ <br /> J <br /> Q <br /> / DEPARTMENT USE ONLY <br /> Application Accepted By ll� Date Area O� Employee ID# le <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# WellID# <br /> Codes Info By Cash Remitted Service Request# <br /> -1 1 tgl 2L3 3 (S44VO720 -7e <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4/30/12 <br />