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DC-GB 0126 <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOC!'CTON CA 95205-6232(209)468-3420 <br /> NON-REFUNDABLE PERMIT WWw.s ov.or /ehd PI/RES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS Southeast Corner of D ST and Washington St CITY/ZIP Stockton,CA 95205 =. <br /> m <br /> D <br /> CROSS STREET Washington ST APIN JCj 7�I�S PARCEL SIZE LAND USE APPLICATION# z <br /> OWNER NAME Pacific Gas&Electric PHONE 1800-468-4743 <br /> OWNER ADDRESS PO Box 997300 CITYISTATEIZIP Sacramento,CA.95899 <br /> CONTRACTOR Gregory Drilling Inc. PHONE 425-869-2372 <br /> CONTRACTOR ADDRESS 14112 452nd Ave SE CITY/STATFIZIP North Bend,WA 98045 <br /> SUBCONTRACTOR/CONSULTANT_ PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CRY/STATE/ZIP <br /> LICENSE X C-57 C-61 i i D-09 i I Other NUMBER 1007649 EXPIRATION DATE 1-31-2021 <br /> BILLING PARTY: I I OWNER 9 CONTRACTOR D SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING:�j General Mineral/Coliform Bacteria(4391)11 Dibromochloropropane(4392)CI Arsenic(4393) <br /> INTENDED USE Domestic/Private D Irrigation/Agricultural X Industrial i-Water Quality Monitoring D Soil Sampling/Characterization <br /> - Public Water System <br /> If different from Owner: Water System Name Contact Name or Plane Number <br /> TYPE OF WORK D New Well I I Replacement Well ❑Well Alteration/Modification X Other Cathodic Protection <br /> D Monitoring Well(s) #of wells D Soil Boring(s) #of borings D Geotechnical #of borings <br /> D Out-Of-Service Well D Out-Of-Service Well Renewal D Cross-Connection Repair <br /> D New Pump n Pump Replacement D Pump Repair D Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Ro:ary I Air Rotary -.Auger ❑Cable Tool D Push Point X Other Sonic <br /> Proposed Well Depth 200 ft Excavation 8 in diameter D Open Bottom X Gravel Pack/Gravel Size Coke in diameter <br /> '1 Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter 2 in Thickness/Gauge/ASTM Schad X Steel D Plastic D Stainless Steel D Other <br /> Grout Seal Depth 9 J, ft X Neat Cement(94 lb bag/5-10 gal water) ❑Sand Cement sack m&(7 gal water <br /> Bentonite(20%solids) n Other <br /> Grout Placement Method X Pumped D Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By i Driller I! Pump Contractor Other <br /> Concrete Pedestal UDimensions:Width ft Length If Thick in I I Christy Box h Stove Pipe <br /> PUMP I-. Submersible I I Turbine '.1 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. 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 /> MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-769 <br /> SIGNED1 TITLE Vice President DATE 1/12/2020 <br /> � rV�® <br /> Z 2020 <br /> SAN (R4NM CQUNTY <br /> --WEAL <br /> H DEPARTMLNT <br /> ll A TMENT U E ONLY <br /> Application Accepted By Date Area Employee ID#-iA <br /> Grout Inspection By Date ZG � _ SPECIAL Well Permit <br /> '?o <br /> Pump Inspection By Date _ WAIVER Received <br /> Soil Boring In action By Date Constructed Well Depth 1� 1 ft` <br /> COMMENTS 77O✓LT SPaI ��G��cI Ii�t QQ_r_ �C <br /> 4 h 4- <br /> PE SC Received Chec Amount Date Permit/ Invoice# Well ID# <br /> Codes Info Remitted Serviw Request# <br /> 7j, 1 <br /> EHD43-06 6/11/2019 WELL/PUMP PERMIT <br />