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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 />NUN-KEFUNDABLE PERMIT t:ALL (ZU9) 953-7697 FOR INSPECTIONS hAi IKhb 1 YEAR FROM LIA <br />JOB ADDRESS 26180 N. Nowell Rd CITY/ZIP Thornton / 95686 <br />CROSS STREET N. New Hope Rd APN 001-230-21 PARCEL SIZE 23.3 LAND USE APPLICATION # <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 I C-57 I I C-61 I I D-09 Other <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br />INTENDED USE 7 DOmesbrJPrlvale Cl Irrigation/Agricultural I Industrial -:I Water Quality Monitoring, oil Sampling/Characleriza Io <br />7 Public Water System <br />If different from Owner. water byritern Name contact Name or Phone Numb., <br />TYPE OF WORK 7 New Well ❑ Replacement Well :. Well Alteration/Modification -1 Other <br />Monitoring Well(s)_ 1 # of wells U Soil Boring(s) a of bongs t: Geolechnical ate* z of banngs <br />-1 Out -Of -Service Well L Out -Of -Service Well Renewal U Cross -Connection Repair <br />Drilling Method -1 Mud Rotary ] Air Rotary C Auger D Cable Tool 9 Push Point l Other <br />Proposed Well Depth 30 ft Excavation 6 in diameter U Open Bottom U Gravel Pack/Gravel Size in diameter <br />I Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched D Steel C Plastic U Stainless Steel D Other <br />Grout Seal Depth ft I I Neat Cement (94 Ib bag/5-10 gal water) D Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) " Other <br />Grout Placement Method iI Pumped i Free Fall I I Other I Retardant/ Accelerator (name) <br />Es Installed By iJ Driller U Pump Contractor IL Other <br />J Concrete Pedestal Dimensions: Width R Length R Thick In I I Christy Box O Stove Pipe <br />PuMP I Submersible ; Turbine E Other HP Pump Set fl 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 />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />DEPARTMENT USE ONLY <br />Date <br />Date <br />Date <br />Date <br />Area____ Employee ID# <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth <br />M <br />N <br />PE <br />Codes <br />PHONE <br />CITY/STATE/ZIP <br />PHONE 209-577-4333 <br />CITY/STATE/ZIP <br />Modesto / CA / 95354 <br />PHONE 916-371-8234 <br />CITYISTATE21P <br />West Sacramento / CA / 95691 <br />NUMBER 969927 <br />EXPIRATION DATE 02/26/2016 <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br />INTENDED USE 7 DOmesbrJPrlvale Cl Irrigation/Agricultural I Industrial -:I Water Quality Monitoring, oil Sampling/Characleriza Io <br />7 Public Water System <br />If different from Owner. water byritern Name contact Name or Phone Numb., <br />TYPE OF WORK 7 New Well ❑ Replacement Well :. Well Alteration/Modification -1 Other <br />Monitoring Well(s)_ 1 # of wells U Soil Boring(s) a of bongs t: Geolechnical ate* z of banngs <br />-1 Out -Of -Service Well L Out -Of -Service Well Renewal U Cross -Connection Repair <br />Drilling Method -1 Mud Rotary ] Air Rotary C Auger D Cable Tool 9 Push Point l Other <br />Proposed Well Depth 30 ft Excavation 6 in diameter U Open Bottom U Gravel Pack/Gravel Size in diameter <br />I Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched D Steel C Plastic U Stainless Steel D Other <br />Grout Seal Depth ft I I Neat Cement (94 Ib bag/5-10 gal water) D Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) " Other <br />Grout Placement Method iI Pumped i Free Fall I I Other I Retardant/ Accelerator (name) <br />Es Installed By iJ Driller U Pump Contractor IL Other <br />J Concrete Pedestal Dimensions: Width R Length R Thick In I I Christy Box O Stove Pipe <br />PuMP I Submersible ; Turbine E Other HP Pump Set fl 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 />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />DEPARTMENT USE ONLY <br />Date <br />Date <br />Date <br />Date <br />Area____ Employee ID# <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth <br />M <br />N <br />PE <br />Codes <br />SC <br />Info <br />Received Check#/ Amount Data Permlf/ Invoice# Well ID# <br />By Cash Remitted Service Request 9 <br />c�Pbo3738� <br />EHD 43-0W WELL /PUMP PERMIT <br />aro4roe <br />