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C-1609 WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />NON-REFUNDABLE PERMIT <br />JOB ADDRESS 16 e MJ E 5TH ST <br />tXPIKtb 1 YEAR FROM DATE ISSUED <br />CITY/ZIP Stockton, 95206 <br />CROSS STREET S. American APN 16 / / S1j-PARCEL SIZE _ _LAND USE APPLICATION # <br />OWNER NAME PG&E IN Csr� PHONE <br />OWNER ADDRESS 3965 Occidental Road CrrY/STATEIZIP Santa Rosa, CA 95401 <br />CONTRACTOR Gregory Drilling PHONE 530-565-6289 <br />CONTRACTOR ADDRESS 14112 452nd Ave SE CITY/STATE/ZIP North Bend, WA 98045 <br />SUBCONTRACTOR/CONSULTANT Barnard Construction PHONE 406-586-1995 <br />SUBCONTRACTOR/CONSULTANT ADDRESS 701 Gold Ave CITY/STATE/ZIP Bozeman, MT 59715 <br />LICENSE X C-57 C-61 D-09 Other NUMBER 1007649 EXPIRATION DATE 1-31-23 <br />BILLING PARTY: OWNER XCONTRACTOR SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <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 Contact Name or Phone Number <br />TYPE OF WORK XNew Well Replacement Well Well Alteration/Modification X Other Cathodic Protection <br />Monitoring Well(s) # of wells Soil Boring(s) # of bodngs Geotechnical # of borings <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />WELL CONSTRUCTION <br />Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point X Other Sonic <br />Proposed Well Depth 100 ft Excavation in diameter Open Bottom X Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth It Calcined Coke Breeze <br />Well Casing Diameter 2 in Thickness/Gauge/ASTM Sched 40 Steel X Plastic Stainless Steel Other <br />Grout Seal Depth 59 ft X Neat Cement (94 Ib bag15-10 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 />PEDESTAL Installed By Driller Pump Contractor Other <br />Concrete Pedestal Dimensions: Width It Length It Thick in Christy Box Stove Pipe <br />PUMP Submersible Turbine Other HP Pump Set It 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. 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 />MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED v --1- TITLE President DATE 5-24-21 <br />DEPARTMENT USE ONLY L AS - <br />Grout <br />Application Accepted By Lr ` Date S J % Area ' bek `j VlEmployee ID# <br />Inspection By Date IA -LA SPECIAL Well Permit <br />Pump Inspection By Date WAIVER Received <br />Soil Boring Inspection Byate Constructed Well Depth ft <br />COMMENTS PI i2pl tl/eC1'or eed <br />PE Sc Received <br />Codes Info <br />Check#/ <br />Cash <br />Amount Date Perm1U Invoice# WeI11D# <br />Remitted Service Re uest# <br />I i$1 <br />�- <br />3?5W <br />EHD 43-06 6/11/2019 �y /,2SF ^,F2_Z / WELL/PUMP PERMIT <br />FN_8Aq <br />CF/V' D <br />Y21 <br />?021 <br />Qv(N <br />EPaRT�NTY <br />T <br />