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pvrc <br />WPov3?yo0-1311 <br />WELL/PUMP PERMIT <br />Inenu,n, Cnuury Furnonuuaurer HF<LTH DEPARTMENT 600 EAST MAIN STREET - STOCKTON CA 95202 - (209) 468-3420 <br />NON-REFUNDABI,EPERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 7 YEAR FROM DATE ISSUED <br />5400, 686, & 6701 W. Kile Rd r J1 CITyl7jP Thornton / 95242 <br />JOB ADDRESS <br />UU1 L <br />N. Nowell Rd & N. Ray Rd APNnnJ-;1rr U6 n11 -120-n2 PARCEL SIZE 166.6 <br />CROSS STREET LAND USE APPLICATION# <br />'/�1 <br />OWNER NAME D e A 14Gr 46' PHONE <br />OWNER ADDRESS <br />147 1- UJ I'( 1 e, CITYISTATEIZIP d 1 <br />CONTRACTOR Kleinfelder, Inc. PHONE __.20&577-4333 <br />CONTRACTOR ADDRESS 1224 6th Street CITYISTATEIZIP Modesto / CA / 95354 <br />SUBCONTRACTOR PHONE tr <br />SUBCONTRACTOR ADDRESS CI�I,,TYI�YI��S,,TAATEE�IIIIZ''IIP'']] y, <br />LICENSE C 57 C-61 D-09 Other NUMBER 9e7 )—Si EXPIRATION DATE _ f� <br />Coordinates x Y Township_ Range Section_ <br />EGGRAPHICA <br />NTENDED USEL (VDomestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring oil Sampling/CharacterizaUo <br />Public Water System <br />Irdlfferent from Cwner a er ys em ame Contact Name or one um er <br />TYPE OF WORK New Well Repla meet Well Well Alteration/Modification Vlner -- <br />H of borings <br />Monitoring Well(s) #of wells Soil BoringM of borings Geotechnical <br />Boring(s) _ <br />Out-Of-SerWe Out -Of -Service Well Renewal Cross -Connection Repair <br />WELL CONSTRUCTION <br />Drilling Method <Ed Rot Air Rotary u er Cable Tool Push Point Other <br />Proposed Well Depth 30-60 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 Schad Steel Plastic Stainless Steel Other <br />Grout Seal Depth ft JLNeat Cement (94 /b bag/5-10 gal water) Sand Cement sack mix/•1 gal water <br />Bentonite (20° 'ds) Other <br />Grout Placement Method umped Free Fall Other Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor Other <br />Concrete Pedestal Dimensions: Width it Length ft Thick in Christy Box Stove Pipe <br />PUMP Subrnersible Turbine Other HP _ Pump Set ft Standing Water Level _ It <br />I HEREBY CERTIFY THAT 1 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 />�jy�+� / /MINIMUM �24 HOUR ADVANCE NOTPE REQUIRED FOR INSPECTIONS <br />T11 Project Engineer DATE _ _ 10/2117 <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS n I . <br />T <br />n <br />°o <br />m <br />N <br />E-PARTMENT Ugg %t�.LY G <br />`//,, i 7// C%J ! t c <br />Date I v Area / / Employee ID# <br />%j� Dater SPECIAL Well Permit <br />V Date WAIVER Received <br />r Al lie r r �! (ryl h, <br />