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Y <br />UJ P® C 73 K5 <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 EAST MAIN STREET - STOCKTON CA 95202 - (209) 468.3420 <br />JOB ADDRESS6"4 6 6651 . Peltier Rd CITY21P Thornton 195242 <br />CROSS STREET N. Thornton Rd pp011-120- 1&011-130-38 PARCEL SIZE 43.5 LAND USE APPLICATION# <br />OWNER NAME / 1 I, CPHONE <br />OWNER ADDRESS �O IJ X / 0/t� CITYISTATE/ZIP J 4Uc ^ 4� <br />CONTRACTOR Kleinfelder,Inc. PHONE 209-577-4333 <br />CONTRACTOR ADDRESS 1224 6th Street CITYISTATE/ZIP Modesto / CA / 95354 <br />SUBCONTRACTOR �� PHONE 6464;4.82 <br />SUBCONTRACTOR ADDRESS CITY/STATEI-ZI7P77 LL^^ <br />LICENSE C-57 C-61 D-09 Other NUMBER — W+`~7 t.,IRATION DATE ____,,____uu__--,, '4 5(T <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section <br />NTENDED USE Domestic/Private Inigatlon/Agricullural Industrial Water Quality Monitoring oil Sampling/Characterizal o <br />Public Water System <br />If different from Owner water 5ySteM NaMe Confact name or Pnone NumBer <br />TYPE OF WORK New Well Replacement Well Well Alterallon/Modificetion Other <br />Monitoring Well(s) # of wells Soil Boring(s) # of bodngs Geotechnical (i # of borings <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair 3 <br />Drilling Method <Jud Rota Air Rotary uger 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 Depth ft Ir Neat Cement (94 lb bag/5-10 gal water) Sand Cement sack mix17 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Metholf Pumped 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 Plpe <br />u p 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 />ID <br />O <br />4 <br />Application Accepted By Date o Area G t Employee IDN <br />Grout Inspection By Date J��SPECIAL Well Permit <br />VV <br />Pump Inspection By Data 1 WAIVER Received <br />Soil Boning In it By _ _ Date Constructed Well Depth ft <br />COMMENTS IK 1 l <'6 /' ( /w UO li <br />PE <br />Codes <br />Sc <br />Info <br />Received C / <br />B Cash <br />Amount Date <br />Remitted <br />Permit/ Invoice # Well IDN <br />Service Re uest# <br />U3"} <br />ISu <br />4C <br />y3 <br />W d%37 . <br />E{D 43-H <br />MIDI! <br />WELL /PUMP PERMIT <br />