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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> CO�7 r f r /� ua <br /> JOB ADDRESS L I L 1 1V � f [ r-.,;.;r f[ ,:' CITYIZIP �(n'� }D °�F i 2 7 J m <br /> D <br /> �y o <br /> CROSS STREET L `'�t`C;� 1zA APN "` PARCEL SIZE / LAND USE APPLICATION# X <br /> OWNER NAME C/`�J ( ,(tI,T��. PHONE <br /> OWNER ADDRESS CITYISTATEIZIP CSl!/�► <br /> CONTRACTOR Kleinfelder, Inc. PHONE 209-948-1345 <br /> CONTRACTOR ADDRESS 2001 Arch Airport Road, Suite 100 CITY/STATE/ZIP Stockton, CA 95206 <br /> SUBCONTRACTOR V&W Drilling PHONE 209-369-9600 <br /> SUBCONTRACTOR ADDRESS 3806 Duck Creek Dr. CITY/STATE/ZIP Stockton, CA 95215 <br /> LicENSE X C-57 C-61 I D-09 I Other NUMBER 720904 EXPIRATION DATE 4-30-2018 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE Domestic/Private Irrigation/Agricultural i Industrial i Water Quality Monitoring 1 i Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water System Name Contact Wam—e or Phone Number <br /> TYPE OF WORK New Well Replacement Weli I Well Alteration/Modification I Other <br /> Monitoring Well(s) #of wells I Soil Boring(s) #of borings X Geotechnical 2 #of borings <br /> Out-Of-Service Well I Out-Of-Service Well Renewal i Cross-Connection Repair <br /> - New Pump Pump Replacement I Pump Repair i Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary 1 Air Rotary XAuger Cable Tool Push Point I : 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 / Conductor Casing Depth ft <br /> Well Casing Diameter_ in Thickness/GaugeIASTM Sched -1 Steel Plastic I Stainless Steel I Other <br /> Grout Seal Depth ft X Neat Cement(94 lb bag15-10 gal water) Sand Cement sack mix17 gal water <br /> I Bentonite(20%solids) Other <br /> Grout Placement Method X Pumped Free Fall Other I Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> I Concrete Pedestal Dimensions:Width ft Length ft Thick in I 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 /> WORKE COMPENSATION LAWS. <br /> NI M 2 H UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br /> SIGNED t/ ` TITLE Project Geologist DATE 5-26-1 <br /> vi <br /> s <br /> rh P <br /> D PARTMENT SE ONLY <br /> I <br /> Application Accepted By Date 1r�- Area Employee ID#� <br /> Grout Inspection By - Date KJ 0 PECIAL Well Permit <br /> Pump Inspection By Dake 11 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS I / u <br /> PE Sc Rec ived Che #f Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By_ Cash Remitted Service Request# <br /> J_!�D ag_ A/91 `olG -77 <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4130112 <br />