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C-1685 WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />Joe ADDRESS NE Corner of Ventura Ave & W Washington t CITYruP Stockton, CA 95203 <br />CROSS STREET Ventura Ave APN ROW PARCEL SIZE LAND USE APPLICATION # <br />OWNER NAME PG&E PHONE <br />OWNER ADDRESS 3965 Occidental Road CITYISTATEIZIP Santa Rosa, CA 95401 <br />CONTRACTOR Gregory Drilling PHONE 530-565-6289 <br />CONTRACTOR ADDRESS 14112 452nd Ave SE CITY/STATEalP North Bend, WA 98045 <br />SUBCONTRACTORICONSULTANT Barnard Construction PHONE 406-586-1995 <br />SUBCONTRACTOR/CONSULTANT ADDRESS 701 Gold Ave CtrY/STATEIZIP Bozeman, MT 59715 <br />LICENSE X C-57 C -fit _ D-09 Other NUMBER 1007649 EXPIRATION DATE 1-31-23 <br />BILLING PARTY: OWNER XCONTRACTOR ... SUBCONTRACTORICONSULTANT <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) _ Dibromochloropropane (4392) Arsenic (4393) <br />NTENDED USE _. Domesfic/Private __ IrrigationlAgricultural Industrial - Water Quality Monitoring Soil Sampling/Charppedzabon <br />Public Water System <br />II different fro n Owner Water System Name Contact Name or Phomt Number <br />TYPE OF WORK New Well Replacement Well Well AllerationrModification X Other Cathodic Protection <br />Monitoring Welf(s) # of wells Soil Bonng(s) 6 of borings - Geotechnical r of bonngs <br />Out -Of -Service Well Out -Of -Service Well Renewal - Cross -Connection Repair <br />New <br />)rilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point X Other Sonic <br />proposed Well Depth 58 ft Excavation in diameter Open Bottom X Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft Calcined Coke Breeze <br />Well Casing Diameter 2 in Thickness/Gauge/ASTM Schad 40 Steel X Plastic Stainless Steel Other <br />Grout Seal Depth 20 ft X Neat Cement (94 Ib bag/5-10 gal water) Sand Cement sack mixn gal water <br />Bentonite (20% solids) Other <br />3rout Placement Method X Pumped - Free Fall Other Retardant /Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor X Other Barnard Construction <br />Concrete Pedestal _-Dimensions: Width ft Length h Thick in X Christy Box Stove Pipe <br />PUMP Submersible Turbine Other HP Pump Set ft Standing Water Level It <br />1 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 130ARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />_v <br />SIGNEDTITLE President DATE 5-24-21 <br />LA <br />D <br />0 <br />A <br />w <br />D A MENT U E ONLY <br />Application Accepted By —ate Area Employee ID# <br />Grout Inspection By �/� Date PECIAL Well Permit <br />Pump Inspection By Date WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth h <br />COMMENTS <br />%ill R'��/1//.�l �I�L���t�L�1Lir3�f�ll►I�'I?:!�IL.�� <br />EHD 4346 6/110019 W /-;�S--! / _ — _ WELL /PUMP PERMIT <br />