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i <br />1� <br />W P 00373W3T 40a- <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 EAST MAIN STREET - STOCKTON CA 95202 - (209) 468-3420 <br />LE PERMIT I:ALL ZUldSb3-1139/ FOR INSPECTIONS tAPIKtb T YEAR FROM LJAIE ISSUED <br />JOB ADDRESS 26180 N. Nowell Rd <br />Amount <br />Remitted <br />CITY/ZIP <br />Thornton / 95686 <br />CROSS STREET N. New Hope Rd <br />APN 00(1�-230-21 <br />PARCEL SIZE 23.3 <br />LAND USE APPLICATION# <br />OWNER NAME U it \ V <br />y fy�h `•t fill C <br />PHONE <br />U <br />ny I 1 r1('- <br />OWNER ADDRESS J <br />1.) <br />CITY/STATE/ZIP <br />CONTRACTOR Kleinfelder, Inc. <br />PHONE 209-577-4333 <br />CONTRACTOR ADDRESS 1224 61h Street <br />CITY/STATE/ZIP <br />Modesto / CA / 95354 <br />SUBCONTRACTOR ril r1mr <br />PHONE <br />SUBCONTRACTOR ADDRESS <br />CITY/STATE/ZIP <br />"�'5 l 3� /1 <br />LICENSE I C-57 C-61 D-09 <br />I Other <br />NUMBER ^9699 `'rte/ <br />EXPIRATION DATE OW2812oTs' V <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township _ Range Section <br />NTENDED USE 7 DomesBrJPrivate ❑ Irdgation/Agdcullurai C Industrial 7 Water Quality Monitoring <EggSampling/Characterize o <br />7 Public Water System <br />If different from Owner Water system Nam CoritildNamaorprion. um er <br />TYPE OF WORK 7 JJew Well -3 R acement Well E Well Alleration/Modification 7 Other <br />Monitoring Well(s) # of wells P Soil Boring(s) 0 of Wrings F Geotechnical a or Lodnys <br />Out -Of -Service Well C Out -Of -Service Well Renewal D Cross -Connection Repair <br />New PumD 7 Pump Replacement ❑ Pump Repair U Raise Well Casino <br />Drilling Method 7 Mud Rotary J Air Rotary [(Auger D Cable Tool 3 Push Point J Other <br />Proposed Well Depth 30—ft Excavation 6 In diameter ❑ Open Bottom O Gravel Pack/Gravel Size In diameter <br />IConductor Casing in diameter / Conductor Casing Depth it <br />Well Casing Diameter _ In Thlckness/Gauge/ASTM Schad a Steel E Plastic u Stainless Steel ❑ Other <br />Grout Seal Depth 1t AwNeat Cement (94 lb bag/5-10 gal water) a Sand Cement sack mix// gal water <br />_1 Bentonite (20% solids) J Other <br />Grout Placement Method rumped u Free Fall a Other J Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller D Pump Contractor :1 Other <br />J Concrete Pedestal Dimensions: Width fl Length It Thick In 0 Christy Box D Stove Pipe <br />PUMP J Submerslbl8Ll Turbine u Other HP Pump Set R Standing Water Level ft <br />IHEREBY 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. 1 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 />N <br />n <br />m <br />!- z <br />� <br />:�W <br />.� N 6M <br />1 W cv zea <br />U I� a0c <br />aye <br />rn <br />� ) <br />i <br />M— <br />U <br />— <br />e <br />EPARIt)TMENT USE ONLY <br />q U <br />G y <br />Application Accepted By Data �-6 / '1 Area I � � Employee ID# W <br />Grout Inspection By 7. d4l"c Date SPECIAL Well Permit <br />Pump Inspection By Date WAIVER Received <br />Soil Boring InW@dlon By; Y _ Date , r Constructed Well Depth it it <br />PE SC Received Che / <br />Codes Info B sh <br />Amount <br />Remitted <br />Date Permill Invoice # Well ID# <br />_ _Service Regue2sctl# — -..._ <br />.iTVRJ+rte <br />r <br />(l� {7"� 7 W ,�'•�1i�7 7t,� <br />EHD 43 06 <br />em/09 <br />WELLIPUMP PERMIT <br />