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JE WELL/PUMP PERMIT ZoI�4421.�`� i cx)o 0 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN-KEFUNDABLE HERMIT UALL (LUy) yb.5-/by/ FOR INSPECTIONS t7kI`IKt, I YEAR FROM UATE ISSUED <br />JOB ADDRESS 9251 W. Arbor Avenue CITY/ZIP Tracy/95304 <br />CROSS STREET S. Holly DriveY n APN 212-16-011 PARCEL SIZE 17.10 LAND USE APPLICATION # <br />OWNER NAME /Cil l I` / PHONE <br />� <br />OWNER ADDRESS �JZl7 (.T_l�I�� CITY/STATE/ZIP <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 Inc. <br />SUBCONTRACTOR ADDRESS 3806 Duck Creek Drive <br />LICENSE XC -57 C-61 D-09 1 i Other, <br />PHONE (209)469-7700 <br />CITY/STATE/ZIP Stockton/CA/95215 <br />NUMBER 720904 <br />EXPIRATION DATE 4/30/2018 <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br />INTENDED USE I Domestic/Private I Irrigation/Agricultural it Industrial I Water Quality Monitoring ,?,-Soil Sampling/Characterization <br />Public Water System <br />If different from Owner: Water System Name _____C_onTact Name or Phone Number <br />TYPE OF WORK I New Well I Replacement Well I Well Alteration/Modification I I Other <br />I Monitoring Well(s) # of wells I Soil Boring(s) # of borings Geotechnical 2 # of borings <br />Out -Of -Service Well I Out -Of -Service Well Renewal I I Cross -Connection Repair <br />i New Pump I I Pump Replacement I Pump Repair I I Raise Well Casing <br />Drilling Method X Mud Rotary I Air Rotary I I Auger Cable Tool I I Push Point ! Other <br />Proposed Well Depth 40-75 ft Excavation e� in diameter I Open Bottom I Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched 1 Steel Plastic Stainless Steel I Other <br />Grout Seal Depth ft )C Neat Cement (94 Ib bag/5-10 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 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 />77ZUT <br />HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED TITLE Project Geologist DATE 3/21/2017 <br />EPLRTMENT USE ONLY <br />Application Accepte Date Til Areaed-rphcy Employee ID# - ULO <br />Grout Inspection By Date ❑ SPECIAL Well Permit <br />Pump Inspection By Date ❑ WAIVER Received <br />Soil Boring Inspection By � Date 2 Constructed Well Depth ft <br />COMMENTS / �� u '—� f G,�Oyk <br />ZZ <br />PE <br />Codes <br />SC <br />Info <br />Received <br />B <br />Check#/ <br />Cash <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # <br />Well ID# <br />z <br />M�osuk°� <br />��,° <br />32�1►� <br />1200 <br />0Poo 3�g0r <br />EHD 43-06 WELL /PUMP PERMIT <br />4/30/12 <br />