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In <br />WPDo373r? <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 EAST MAIN STREET - STOCKTON CA 96202 - (209)4683420 <br />t►ji <br />27289 N. ope Rd & 26901 N. Nowell Rd. Thornton 195686 <br />JOB ADDRESS CITY/ZIP <br />CROSS STREET N. Nowell Rd A N001-2 0-3 <br />14 001-230-27 PARCEL SIZE 31.36 LAND USE APPLICATION# <br />OWNER NAME q/�� J tr r- PHONE ( / j. ! <br />OWNERADDRESS • C) 6 0 n 1 CITY/STATE21P 'Ohof of TG,n Cw c 6 /J2 <br />CONTRACTOR Kleinfelder, Inc. PHONE 209 -577 -PHONE 209-577-4333 <br />CONTRACTOR ADDRESS <br />z12T24�6th <br />,.Street CITY/STATE/ZIP Modesto / CA 195354 <br />SUBCONTRACTOR "FoInsT—nmyy PHONE Ote'871"26 Q <br />SUBCONTRACTOR ADDRESS CITY/STATE/ZIP 4.96601 <br />Jyrrlsttea�� ���1G <br />LICENSE C-57 C-61 D-09 Other NUMBER <9E'982�-1��1'��%PIRATION DATE <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br />NTENDED USE Domestic/Private Irrigation/Agrlcultural Industrial Water Quality Monitoring o I Sampling/Characterizat o <br />Public Water System <br />If different from Owner Water System Name Contad N.me.r Phan. um <br />TYPE OF WORK New Well Replacement Well Well Alteratlon/Moci fication Other <br />Monitoring Well(s)of wells Soil Boring(s) I <br /># or bednss Y Geotechnical s of boring. <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />Drilling Method (12ud Rota Air Rotary u e 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 it <br />Well Casing Diameter _ In Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br />Grout Seal Depth___it iNeat Cement (94 lb bag75-10 gal water) Sand Cement sack mix/7 gal water <br />Bentonite (20%solids Other <br />Grout Placement Method IkPumped Free Fall Other Retardant /Accelerator (name) <br />PEnEsTAL Installed By Driller Pump Contractor Other <br />Concrete Pedestal Dimensions: Width It Length H Thick in Christy Box Stove Pipe <br />PUMP Submersible Turbine Other HP Pump Set ft 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 />LA <br />O <br />N <br />N <br />PARTMENT USE ONLY <br />Application Accepted By Date Area _qj` C Employee ID# / <br />Grout Inspection By Date SPECIAL Well Permit <br />Pump Inspection By Date WAIVER Received <br />Soil Boring Inspection By Pate I i !.n Constructed Well Depth ft <br />PE <br />Codes <br />SC Received Ch"U1 <br />Info B ash <br />AmountDate <br />Remitted <br />Permill Invoice # Well ID# <br />Service Re uest# <br />y3)2- <br />ISO c <br />3 <br />17 LJ P0037 ..7 <br />I <br />EHO 43-08 <br />8/0/188 <br />WF1.1 /PUMP PERMIT <br />1�— <br />F— <br />i r%- ZQw <br />LIJ N �Z <br />Lia 92 <br />W 000 <br />W v 05� <br />4 �wa <br />w <br />crt _ <br />