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A <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 EAST MAIN STREET - STOCKTON CA 95202 - (209) 4683420 <br />NUN-KEFUNDABLE PERMIT UALL ZU9 953-fbJ1 FOR IN <br />iJOB ADDRESS 27289 N. New Hope Rd & 26901 N. Nowell Rd. <br />CROs STREET N. Nowell Rd APN001-210-34 & 001-230-27 <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 (1 17 C-61 D-09 Other <br />CITY/ZIP Thornton 195686 <br />RCELSIZE 31.36 LAND USE APPLICATION# <br />PHONE <br />CITYISTATEIZIP <br />PHONE 209-577-4333 <br />CITYISTATEIZIP Modesto / CA / 95354 <br />PHONE 916-371-8234 <br />CITY/STATE/ZIP West Sacramento / CA / 95691 <br />NUMBER 969927 EXPIRATION DATE 02/28/2018 <br />GEOGRAPHICAL INFORMATION: Coordinates Y Township_ Range Section_ <br />NTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring oil Sampling/Cllaraclerizaho <br />Public Water System <br />V diff—M !rom Owner a or y, om ome on < ame or one umber <br />TYPE OF WORK New Well Replacement Well Well AlteratioNModiricalion Other <br />/,Monitoring Well(s)of wells Soil Boring(s) if of borings Geotechnical n or borings <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />WELL CONSTRUCTION <br />Drilling Method (12ud Rota Air Rotary u er Cable Tool Push Point Other <br />Proposed Well Depth 30 & 50 tt 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 Neat Cement (94 /b bag/540 gal water) Sand Cement sack mix/7 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 h Length It Thick in Christy Box Stove Pipe <br />------------ <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. 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 />�—♦y MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br />SIGNED ' W -L ! /t aal TITLE Project Engineer DATE 10/2/17 <br />Application Accepted By <br />Grout Inspeclion By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />DEPARTMENT USE ONLY <br />_.. Date _ --- <br />Dale <br />Date <br />Date <br />Area Employee ID# <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth <br />PE SC Received Check#1 Amount PermiU Invoice # Well ID# <br />Codes Info B Cash Remitted Dale Service Re uest # <br />EHD 4306 <br />810-1/08 <br />WELL /PUMP PERMIT <br />