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P/ <br />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 (2091953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />ADDRESS Median of 1-5 along Stockton Deep Water Channel Bridge crrY21P Stockton, 95203 <br />SS STREET West Fremont Street APN PARCEL SIZE LAND USE APPLICATION # <br />IER NAME Public Right of Way PHONE <br />IER ADDRESS NA CITY/STATEMP <br />CONTRACTOR Kleinfellderr /�% PHONE 916-366-1701 <br />CONTRACTOR ADDRESS 1ll76wc1e ' L/ CITY/STATEZP Sacramento, CA 95827 <br />SUBCONTRACTOR Kleinfelder PHONE 916-366-17/1 <br />SUBCONTRACTOR ADDRESS �le CnY/STATE/ZIP Sacramento, CA 5827 <br />LICENSE 4 C-57 C-61 D-09 Other NUMBER 467252 EXPIRATIO ATE 12/31/2019 <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br />INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring 4 S Sampling/Characterization <br />Public Water System <br />If different from Owner vWva er 5yStern Name I I i Name or Phone um <br />TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br />M nga <br />Monitoring Well(s) # of wells Soil Boringof bon <br />s) a Geotechnical 10 S or borings <br />Out -Of -Service Well Out -Of -Service Well Renewal ross-Connection Repair <br />New Pumo Pumo ReDlacement Pumo Renair Raise Well Casino <br />Drilling Method 4 Mud Rotary Air Rotary Auger Cable Tool 70p.:r'� <br />l 4 Other 5 Mud Rotary and 5 CPTs <br />Proposed Well Depth 200 ft Excavation 4 to 6 in diameter Bottom Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casin ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Schad Steel Plastic Stainless Steel Other <br />Grout Seal Depth ft Neat Cement (94 ib bay5-f0 ! water) Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method Pumped Free Fall QQ Other Z=14=Retardant! Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor Other <br />Concrete Pedestal Dimensions: Width th ft Thick in Christy Box Stove Pipe <br />PUMP Submersible Turbine Other ' 14P Pump Set ft Standing Water Level it <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS ApPLICATIO1414D THAT THE WORK WILL BE DONE 1 ACCORDANCEWITHWITH SAN <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, A" tIXLES AND FGULATIONS. I ALSO CERTIFY THAT Y REQUIRE? LICENSE IS <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRA ORS STATE LICENSE BOARD AND T T I IN COMPLIA A WITH ALL <br />WORKERS COMPENSATION LAWS. <br />MINIMUM 24 HOUR ADVANCE NjbT/t EQUIRED FOR INSPECTIONS -PLEA CALL (209) 17697 <br />Srnucn L' J- -u--- � \ � �\ Tin G Geoloqist n i, /N17 017 <br />EP <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />RTMENT U E NLY <br />Date <br />Date <br />Date <br />Date <br />N <br />gin <br />a <br />in <br />N <br />4/ <br />RF�F��'T <br />NOV.09 o <br />JO, n <br />�11%fR N fC�O �`fY <br />Area Employee ID#�V ' ' <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth ft <br />PE Sc Received <br />Codes Info BV <br />Check#/ Amount Date Permit/ Invoice # Well ID# <br />Cash Remitted Service Request # <br />fm 5II <br />t OP6037 ? <br />EHD 43-6 <br />4130/12 <br />(� ' -/" `"� vVO/g �7 .♦'rt �� D O ✓� /PUf�IP�M1T / , t Y ) L f <br />