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1U <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1668 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT,,,,, CALL 209 953-7'697 FOR INSPECTIONS EXPIRES 'I YEAR FROM DATE ISSUED <br /> JOB ADDRESS r [� 1� wt�}�7 C CITYIZIP /�I/� <br /> �.G / '✓ m <br /> I D <br /> a <br /> CROSS STREET I�r64 W:"& APN (21106011` PARCEL SIZE 3.7L( LAND USE APPLICATION# <br /> m <br /> c�y � C�czc.�rr� y <br /> OWNER NAME � PHONE n <br /> OWNER ADDRESS } /.S CITYISTATEIZIP � ,�[.L <br /> CONTRACTOR Kleinfelder, Inc. PHONE 209-948-1345 <br /> CONTRACTORADDRESS 2001 Arch Airport Road, Suite 100 CITYISTATEIZIP Stockton, CA 95206 <br /> SUBCONTRACTOR V&W Drilling PHONE 209-369-9600 <br /> SUBCONTRACTOR ADDRESS 3806 Duck Creek Dr. CITYISTATEIZIP Stockton, CA 95215 <br /> LICENSE X C-57 C-61 D-09 Other NUMBER 720904 EXPIRATION DATE 4-30-2018 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE I Domestic/Private -1 Irrigation/Agricultural Industrial Water Quality Monitoring I I Soil Sampling/Characterization <br /> I Public Water System <br /> If different from Owner: Water Syrtem Name on aeName or one Number <br /> TYPE OF WORK I New Well i Replacement Well Well Alteration/Modification I Other <br /> Monitoring Well(s) #of wells Soil Boring(s) #of borings X Geotechnical 1 #of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal I Cross-Connection Repair <br /> New Pump I Pump Re Iacement Pump Repair I Raise Well Casio <br /> WELL CONSTRUCTION <br /> Drilling Method 1 Mud Rotary - Air Rotary IXAuger Cable Tool Push Point _1 Other <br /> Proposed Well Depth ft Excavation 6 in diameter I Open Bottom Gravel Pack/Gravel Size in diameter <br /> I Conductor Casing in diameter 1 Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched I Steel I Plastic I Stainless Steel I Other <br /> Grout Seal Depth ft X Neat Cement(94 lb bag/5-10 gal wafer) 1- Sand Cement sack mix17 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method IX Pumped Free Fall Other I Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller ; Pump Contractor Other <br /> Concrete Pedestal I 'Dimensions:Width ft Length ft Thick in I Christy Box i Stove Pipe <br /> PUMP Submersible Turbine ; Other HP Pump Set ft Standing Water Level ft <br /> I HEREBY CERTIFY THAT 1 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 /> I MU 24 POUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-707 <br /> SIGNED t _ _- TITLE Project Geologist DATE 5-26 <br /> Iry <br /> DA <br /> E <br /> r.. <br /> DEPARTMENT SE VONLY <br /> Application Accepted By Date 1-7 Area-46rq Employee ID# � <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ;A WAIVER Received <br /> Soil Borin Inspection By Date Constructed Well Depth ft <br /> I <br /> COMMENTS <br /> PE SC Rec. ved Ch ck#I Amount Permit) <br /> Codes Info B Cash Remitted Date Service Request# Invoice# Well ID# <br /> M skc o 7�-7 <br /> EHD 43-66 061 WELL IF V P PERMIT <br /> 4130/12 <br />