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1146, <br />A <br />M <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 EASTMAIN STREET - STOCKTON CA 95202 - (209) 468-3420 <br />NON-REFUNDABLE MIT --iv /,I- <br />CALL 209 953-7697 FOR INSPECTIONS <br />EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS �N. Nowell <br />Rd <br />CITY/LP Thornton 195688 <br />CROSS STREET N. New Hope Rd <br />flame" <br />B 4 PARCEL SIZE 3-01 <br />LAND USE APPLICATION # <br />l <br />'—.}T� G M C(J <br />CAPL <br />y l U <br />✓�►L�jvj <br />PHONE <br />OWNER NAME <br />f { <br />I <br />d LI <br />ClWNER <br />ADDRESS / s 1/ + <br />c I _S Z 2 <br />CONTRACTOR Kleinfelder, Inc. <br />Q po <br />[/ r�C <br />�C"ISTAWZJP <br />r -�!,'� <br />YCITYISTATEIZIP <br />PHONE 209-577-4333 <br />CONTRACTOR ADDRESS 1224 6th Street <br />Modesto / CA 195354 <br />SUBCONTRACTOR a of <br />PHONE 91'E�9�i'Bi3rM1— <br />SUBCONTRACTOR ADDRESS <br />CITY/STATE/zIP <br />LA6l} <br />LICENSE C-57 C-61 D-09 <br />Other <br />NUMBER -9690,12 1 <br />ExPiPIRATION DATE <br />iEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br />NTENDED USE Domestic/Private IrrigatlonlAgricultural Industrial Water Quality Monitoring of Sampling/Characterize to <br />Public Water System <br />If dafarent from Ow r. water System Neme Contact Name or Phone Number <br />TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br />Monitoring Wallis) # of wells Sail Boring(s) # of bodnge Geotechnical 2 N of boring. <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />Drilling Method Cjud Rat Air Rotary Auger Cable Tool Push Point Other <br />Proposed Well Depth 30&50 ft Excavation 6 In diameter Open Bottom Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth R <br />Well Casing Diameter _ In Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br />Grout Seal Depth ft 4$ Neat Cement (94 lb bag/5-10 gal water) Sand Cement sack mixf7 gal water <br />Bentonite (20% so ids) Other <br />Grout Placement Method tierum ed Free Fall Other Retardant/Accelerator(name) <br />PEDESTAL Installed By Driller Pump Contractor Other <br />Concrete Pedestal Dimensions: Width it Length it 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. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br />C MPENSATION LAWS <br />N <br />WORKERS O - FF <br />MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS I Z <br />DEPARTMENT USE ONLY qlqq <br />Application Accepted By Date k� %� Area Employee ID# <br />Grout Inspection By Dale %6A / SPECIAL Well Permit <br />Pump Inspection By Date WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth a ft <br />COMMENTS P�t,J 1 A� I a i I Amur ror— S= 1— _ -Ga _Q� l J`16 / `7 <br />PE SC <br />Codes Info <br />Received C4s6k#i <br />B ash <br />Amount <br />Remitted <br />Date <br />Permit/ Invoice # Well ID# <br />Service Re uest# <br />u37� ►s <br />Nt C <br />4 <br />o c�{ <br />cx�"�1 <br />�� <br />✓�►L�jvj <br />EH 43-06 <br />SF04ros <br />WELL /PUMP PERMIT <br />