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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 />N-KEFUNDABLE YERMI1 BALL JZUd) yb3-/ by / I -UK INSPtG I IUNS CA rimmz) 'I T tAK FK(JM UA I t ISSUtU <br />ADDRESS 6450 & 6651 W. Peltier Rd CITY/ZIP Thornton / 95242 <br />SS STREET N. Thornton Rd <br />ER NAME <br />ER ADDRESS <br />APNO11-120-21 & 011-130-38PARCEL SIZE 43.5 LAND USE APPLICATION #___ <br />PHONE <br />CITYISTATEIZIP <br />Kleinfelder, Inc. PHONE 209-577-4333 <br />ADDRESS 1224 6th Street CrrY/STATE/ZIP Modesto / CA / 95354 <br />rOR Taber Drilling PHONE 916-371-8234 <br />rOR ADDRESS 536 Galveston Street CITY/STATE/7JP West Sacramento/ CA/ 95691 <br />C-57 G-61 D-09 Other NUMBER 969927 EXPIRATION DATE 02/28/2018 <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township _ Range Section_ <br />VTENDED USE DOmestic/PrIvate Irrigation/Agricultural Industrial Water Quality Monitoring oil Sampling/Characterize o <br />Public Water System <br />If dW..rl from Owner Water System Name Contact Name or Phone Number <br />TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br />TG Monitoring Wellls)�_ # of wells Soil Boring(s) a or borings ,GGeotechnical a or borings <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />Drilling Method Qjud Rota Air Rotary uger Cable Tool Push Point Other <br />Proposed Well Depth 30-80 ft Excavation 6 in diameter Open Bottom Gravel PacWGravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth It <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Schad Steel Plastic Stainless Steel Other <br />Grout Seal Depth ft Neat Cement (94 lb bag/5-10 gal water) Sand Cement sack mixrl 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 it Length ft Thick in Christy Box -PIP. <br />PUMP Submersible Turbine Other HP Pump Set It Standing Water Level It <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 />Application Accepted By Uate _ Area Employee ID# _ <br />Grout Inspection By Date _ _.. SPECIAL Well Permit <br />Pump Inspection By Date WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth It <br />COMMENTS <br />PE SC Received Check#/ Amount PermiU <br />Codes Info B Cash Remitted Date Service Re uest # Invoice # Well ID# <br />top w,-; <br />END 43.06 <br />8104108 <br />WELL /PUMP PERMIT <br />