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Vort 5os4eri WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1866 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 466-3420 <br />NUN-KEFUNDABLE PERMIT WWW.S OV.Or /ena tAYIKt, l TEAR FROM DATE ISSUED <br />JOB ADDRESS In PROW IFO 16802 Von Sosten Rd, Tracy. (C-1747, PM 74037547) CITy/ZIP Tracy, CA 95304 <br />CROSS STREET Los Ranchos APN 209-380-350-000QWr ARCEL SIZE LAND USE APPLICATION # <br />OWNER NAME Pacific gas and Electric Company PHONE 925-4044064 <br />OWNER ADDRESS 6121 Bollinger Canyon Road, Crn7STATE/ZIP San Ramon, CA 94583 <br />CONTRACTOR American Construction and Supply, Inc. PHONE 415-927-2024 <br />CONTRACTOR ADDRESS 45 San Clemente Dr., Suite A-100 CITY/STATE/ZIP Cone Madera; CA 94925 <br />SUBCONTRACTORICONSULTANT N/A <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />LICENSE ✓ C-57 C-61 <br />BILLING PARTY: OWNER <br />D-09 <br />CITY/STATE/ZIP. <br />Other NUMBER 310599 <br />✓CONTRACTOR SUBCONTRACTOR/CONSULTANT <br />PHONE <br />ExPIRATiON DATE 03/31/2023 <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />NTENDED 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 ✓ New Well Replacement Well Well Alteration/Modification V Other Cathodic Protection <br />MonitoringWell(s) #ofwells SoilBoring(s) #ofborings Geotechnical #ofborings <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />New <br />Drilling Method ✓ Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br />Proposed Well Depth 300' ft Excavation 8„ in diameter Open Bottom ✓ Gravel Pack/Gravel Size 3/8 Coke in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter 2 in Thickness/Gauge/ASTM Sched 40 PVC Steel ✓ Plastic Stainless Steel Other <br />Grout Seal Depth 200' ft ✓ Neat Cement (941b bag/5-10 gal water) Sand Cement sack mix17 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 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. 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 />MINIM R ADtjfti "&k-y€tRtM0IRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED -- Date: 2021.07.1611:51:33 -07'00' TITLE Steve McKim, Vice President DATE July 16, 2021 <br />_LA <br />g <br />0 <br />A <br />m <br />N <br />N <br />DEPARTMENT USE ONLY ! <br />Application Accepted By o Date 7 J.7,W) Area S 7/�—!/� Employee ID#'4S <br />Grout Inspection By -Date Z�, SPECIAL Well Permit <br />Pump Inspection By, Date WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />i i <br />L'�ll�►1�:��rv%T�r■�E#���i�lV��1 <br />J�If1L'U�Sif:� <br />EHD 43-06 6/11/2019 � /y _ / f� � � / � � ��� WELL (PUMP PERMIT <br />Fr <br />O <br />7?> <br />IN,-), <br />/V7- <br />DEPARTMENT <br />T <br />