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J <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN -REFUNDABLE PERMIT CALL ZUy y5;3 -/by( FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 2249 WATERLOO RD CITY/ZIP Stockton / 95207 <br />CROSS STREET WILLIAMS ST APN 119-110-17 2.31 ones <br />PARCEL SIZE LAND USE APPLICATION # <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 />aEOUHAMICAL irvrUHMAnorv: uaorainaies n a' r f ownsmp mange section <br />NTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System <br />II different from Owner: Water System NEime Contact ame or Phone Number <br />-YPE OF WORK ■ New Well Replacement Well Well Alteration/Modification ■ Other Anode Well <br />Monitoring Well(s)__ # of wells Soil Boring(s) n of oormgs Geotechnical # of borings <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />i,4ew rump rurnp rsepiacemerrt rump repair rsaise vven Lasing <br />WELL CONSTRUCTION <br />Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br />Proposed Well Depth 200 ft Excavation 8� in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter 2 i Thi kness/Gauge/ASTM Sched Steel ■ Plastic Stainless Steel Other <br />Grout Seal Depth r ft 7e; Neat Cement (94 /b bag/5-10 gal water) ■ Sand Cement 10.3 sack mfx/7 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method ■ Pumped Free Fall Other Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller Punp 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 ft Standing Water Level Lit <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 />MINI M 24 UR E NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED TITLE Associate Distribution Engineer DATE 6/22/2017 <br />4 <br />G �P <br />0�-OPDo���3QP C�� <br />N <br />m <br />D <br />v <br />v <br />M <br />v: <br />ADEtRTMENT 5E ONLY <br />Application Accepted B 17ate ArealX� Employee ID# rc C3 <br />Grout Inspection By Date 4-1A SPECIAL Well Permit <br />Pump Inspection By Date WAIVER Received <br />Soil Boring Inspec ion By Date _ C/�nstructed Well Depth ft <br />COMMENTS 01 SC:�JAP DF Ze�Z— A,leo•/D ' �� C "� /j-7 <br />PE <br />Codes <br />SC <br />Info <br />Received <br />B <br />Che � <br />ash k, <br />Amount Date <br />Remitted <br />Permit/ <br />Service Request # <br />Invoice # <br />Well ID# <br />o�u,4s�vP003 <br />�- <br />EHD 43-06 <br />4130/12 <br />WELL /PUMP PERMIT <br />