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I ,. r 14 . <br />`lJVO03 7 -3 !Kb <br />4 WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 EAST MAIN STREET - STOCKTON CA 95202 - (209) 4663420 <br />I <br />NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS "PIhttS 1 YEAR FROM LATE ISSUED <br />i <br />JOB ADDRESS (1699- 581 . Kite Rd CITY/ZIP Thornton / 95686 <br />CROSSSTREET N. Nowell Rd A 0001-230-45 001-180-24 PARCEL SIZE 62.6 LAND USE APPLICATION <br />'T # <br />OWNER NAME 1 t\q rn In S }U I` PHO/NE <br />OWNER ADDRESS 7" W . I L CITY/STATEIZIP L O r FT <br />CONTRACTOR Kleinfelder, Inc. PHONE 209-577-4333 <br />CONTRACTOR ADDRESS 1224 6th Street CITY/STATEIZIP Modesto / CA / 95354 <br />SUBCONTRACTOR "in9 PHONE 9?6'37'i�8Z3+t <br />SUBCONTRACTOR ADDRESS 'STMUrCITY/STATEIZIP L <br />xPIRATION DATE-��OT� <br />LICENSE C-57 C-61 D-09 Other NUMBER '@89U291"*1 + E t "/� <br />S . <br />iEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br />NTENDED USE Domesfic/Private Irrigation/Agricultural Industrial Water Quality Monitoring of Sampling/Characterizat o <br />Public Water System <br />I/differentfrom Owner water Syahan Narna contact Name or Phone um er <br />TYPE OF WORK New Well Replacement Well Well Alteration/Modlficalion Other <br /># of wells Soil Boring(s) II or bodnga V Geotechnical w °fbodng. <br />Monitoring Well(s)—A— <br />Out-Of-Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />Drilling Method d Rota Air Rotary uger Cable Tool Push Point Other <br />Proposed Well Depth 30 & 50 it Excavation 6 in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth it <br />Well Casing Diameter _ In Thickness/Gauge/ASTM Schad Steel Plastic Stainless Steel Other <br />Grout Seal Depth ft Neat Cement (94 Ib bag/5-10 gal water) Sand Cement sack mix/7 gal water <br />Bentonite (20% olid Other <br />Grout Placement Method Pumped Free Fall Other Retardant/Accelerator (name) <br />EDESTAL Installed By Driller Pump Contractor Other <br />Concrete Pedestal Dimensions: Width R 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 />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS O <br />S'2 P c1. + rx <br />EHO 4" <br />8104/09 <br />W1 <br />R ADVANCE NOTICE REQUIRED FO <br />T,,, F Project EnginePW <br />0 <br />a <br />D <br />v <br />0 <br />m <br />N <br />EPARTMENT ``USE -ONLY yyy <br />M Date l� / � Area L' Employee lD# Won / <br />Date SPECIAL Well Permit / <br />Date WAIVER Received <br />Date Constructed Well Depth ft <br />u Q <br />#/ Amount Date Permit/ Invoice # Well ID# <br />Ish Remitted Service Roque <br />St # <br />WELL /PUMP PERMIT <br />1- <br />0 <br />N <br />O� ! <br />w <br />Vz <br />�0 <br />c' <br />oo0 <br />rQw <br />0z� <br />ZW-: <br />EPARTMENT ``USE -ONLY yyy <br />M Date l� / � Area L' Employee lD# Won / <br />Date SPECIAL Well Permit / <br />Date WAIVER Received <br />Date Constructed Well Depth ft <br />u Q <br />#/ Amount Date Permit/ Invoice # Well ID# <br />Ish Remitted Service Roque <br />St # <br />WELL /PUMP PERMIT <br />