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1 ' <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 EAST MAIN STREET-STOCKTON CA 95202 - (209) 468.3420 <br />NUN-KtfUNUAtlLt r t:HMl l <br />t,/ALL LUy Z0"-/0yr FUR IN51'tGfI1JN5 <br />CAYIKCA'I T tAK FKUM UA It 155UtU <br />Joe ADDRESS 7500 & 7581 W. Kile Rd <br />CITY/ZIP <br />Thornton / 95686 <br />CROSS STREET N. Nowell Rd <br />APNO01-230-45 & 001 -180-24 PARCEL SIZE 62.8 <br />LAND USE APPLICATION# <br />OWNER NAME <br />PHONE <br />OWNER ADDRESS <br />CITY/STATEIZIP <br />CONTRACTOR Kleinfelder,Inc. <br />PHONE 209-577-4333 <br />CONTRACTOR ADDRESS 1224 6th Street <br />CITY/STATE/ZIP <br />Modesto / CA / 95354 <br />SUBCONTRACTOR Taber Drilling <br />PHONE 916-371-8234 <br />SUBCONTRACTOR ADDRESS 536 Galveston Street CITYISTATE/ZIP <br />West Sacramento / CA / 95691 <br />LICENSE C-57 C-61 D-09 <br />Other NUMBER 969927 <br />EXPIRATION DATE 02/26/2016 <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township _ Range Section_ <br />INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring o Sampling/Characleriza to <br />Public Water System <br />Ir different from Owner a er ys em ams eorenone um r <br />TYPE OF WORK Now Well Replacement Well Well Alleration/Modificalion Other <br />yMonitodng Well(s) I # of wells Soil Boring(s) # of bodngs 1(Geolechnical -� 2, 'f bod gs <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />Drilling Method 4EEd Rola Air Rotary Ser Cable Tool Push Point Other <br />Proposed Well Depth 30 8, 50 ft Excavation 6 in diameter Open Bottom Gravel Pack/Gravel Size In diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter_ In Thickness/Gauge/ASTM Schad _ Steel Plastic Stainless Steel Other <br />Grout Seal Depth ft Neat Cement (941b bag/5-10 gal water) Sand Cement sack m1.x17 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method Pumped Free Fell Other Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor Other <br />Concrete Pedestal Dimensions: Width R Length ft Thick in Christy Box Stove Pip. <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 />DEPARTMENT USE ONLY <br />Application Accepted By _ Date Area Employee ID# <br />Grout Inspection By Dale SPECIAL Well Permit <br />Pump Inspection By Date WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />PE Sc Received Check#/ <br />Codes Info By Cash <br />Amount Date Permit/ Invoice # Well ID# <br />R.mitted Service Re uest# <br />Wog,,s 6 <br />EHO 43-08 <br />erooros <br />WELL /PUMP PERMIT <br />