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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 EAST MAIN STREET - STOCKTON CA 95202 - (209) 468-3420 <br />NUN-MEFUNDABLE PERMIT GALL (ZU9) 953-76: <br />JOB ADDRESS 26777 & 26982 N. Nowell Rd <br />CROSS STREET N. New Hope Rd APN 001-230-028,41 <br />OWNER NAME <br />OWNER ADDRESS <br />CONTRACTOR Kleinfelder, Inc. <br />CONTRACTOR ADDRESS 1224 6th Street <br />SUBCONTRACTOR Taber Drilling <br />SUBCONTRACTOR ADDRESS 536 Galveston Street <br />LICENSE C-57 C-61 D-09 Other <br />:TIONS <br />EXPIRES 1 YEAR FROM DATE ISSUED <br />CITY/ZIP <br />Thornton / 95686 <br />FLSIZE 3.01 <br />LAND USE APPLICATION # <br />PHONE <br />CITY/STATE/ZIP <br />PHONE 209-577-4333 <br />CITY/STATE/ZIP Modesto / CA 195354 <br />PHONE 916-371-8234 <br />CITY/STATEIZIP West Sacramento / CA / 95691 <br />NUMBER 969927 EXPIRATION DATE 02/28/2018 <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section <br />INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring oil Sampling/Characterizatlo <br />Public Water System <br />If different from OwnerWaTer S sremame (;.nt.cttAame or Fhone U lar <br />TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br />4(MonitoringWell(s)�_#of wells SoilBoring(s) #or borings v(Geotechnical 01 otborings <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />New Pump Pump Replacement Pump Repair Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method ud Rota Air Rotary Auger 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 R <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched Sleet Plastic Stainless Steel Other <br />Grout Seal Depth _it Neat Cement (94 Ib bag/5-10 gal water) Sand Cement_ sack mix17 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method Pumped Free Fall Other Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor Other <br />Concrete Pedestal Dimensions: Width ft Length it Thick in Christy Box Stove Pipe <br />PUMP Submersible Turbine Other HP Pump Set it Standing Water Level ft <br />1 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 />/ /MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br />Q <br />SIGNED f I'1Ltk- 1 "�-V�Zz TITLE Project Engineer DATE 1012/17 <br />DEPARTMENT USE ONLY <br />Application Accepted By Dale Area _ Employee ID# __._.__ <br />Grout Inspection By _ Date _ SPECIAL Well Permit <br />Pump Inspection By Dale WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />PE SC Received Check#/ Amount Permit/ <br />Codes Info B Cash Remitted Date Service Request # Invoice # Well ID# <br />OFD 317'551 <br />EH O 43.06 WELL /PUMP PERMIT <br />8,04108 <br />