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• 4 <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 EAST MAIN STREET • STOCKTON CA 95202 - (209) 468-3420 <br />NUN -REFUNDABLE PERMIT GALL (1139) 955-7691 FOR INSPECTIONS <br />tAVIRtS 1 YEAR FROM <br />Jos ADDRESS 24597, 25400, 6686, & 6701 W. Kile Rd <br />CITY/ZIP <br />Thornton 195242 <br />CROSS STREET N. Nowell Rd & N. Ray Rd APNnn1-7sn-ns 011 <br />-17n -n7 PARCEL SIZE 166.6 <br />LAND USE APPLICATION#_ <br />OWNER NAME <br />PHONE <br />OWNER ADDRESS <br />CITY/STATE/ZIP <br />CONTRACTOR Klelnfelder, Inc. <br />CONTRACTOR ADDRESS 1224 6th Street <br />SUBCONTRACTOR Taber Drilling <br />SUBCONTRACTOR ADDRESS 536 Galveston Street <br />LICENSE C-57 C-61 D-05 <br />Other NUMBER <br />PHONE 209-577-4333 <br />Cm/STATE/ZIP Modesto / CA / 95354 <br />PHONE 916-371-8234 <br />CITY/STATE/LP West Sacramento / CA / 95691 <br />969927 EXPIRAnON DATE 02/28/2018 <br />TE <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section_ <br />VTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring of Sampling/Characterizatto 1 <br />Public Water System <br />It different I— Owner water system Name on ac ame or one Umber <br />TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br />re Monitoring Wells) 3 # of wells Soil Boring(s) # of borings Geotechnical # of borings <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair -51 <br />Drilling Method <&d Rot Air Rotary <u er Cable Tool Push Point Other <br />Proposed Well Depth 30-80 R 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 Sched Steel Plastic Stainless Steel Other <br />Grout Seal Deplh ft Neat Cement (941b bag/5-10 gal water) Sand Cement sack mW7 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method Pumped Free Fell Other Retardant / Accelerator (name) <br />EDEs A Installed By Driller Pump Contractor Other <br />Concrete Pedestal Dimensions: Width M Length It Thick in Christy Box Stove Pipe <br />PUM1IP Submersible Turbine Other HP___ Pump Set It 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. 1 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 <br />WORKERS COMPENSATION LAWS. A \`,/�� <br />MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS,— <br />SIGNED <br />SIGNED _� TITLE Project Engineer DATE 10/2/17 <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />ARTMENT USE ONLY <br />Date <br />Date <br />Date <br />Date <br />Area Employee ID# <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth <br />PE Sc Received Checkl// Amount Date Permit/ Invoice# Well ID# <br />Codes Into B Cash Remitted Service Re uest # <br />M <br />EHD 43-09 WELL /PUMP PERMIT <br />8104iC8 <br />En <br />ti <br />0 0 <br />m <br />N <br />