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il <br />lf� <br />W P 00373W3-f'A0a- <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 EAST MAIN STREET - STOCKTON CA 95202 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT <br />CALL 209 953-7697 FOR INSPECTIONS <br />EXPIRES 1 YEAR FROM DATE ISSUED <br />Joe ADDRESS 26180 N. Nowell Rd <br />sl�-tel" <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 />, V <br />OWNER NAME U(�n <br />iJ r r \ Y 4 I:' <br />PHONE <br />�UUI <br />I ��i�(;- <br />Greed Rud`41 <br />OWNERADDRESS v <br />IJP <br />CITY/STATE/ZIP <br />CONTRACTOR Klelnfelder, Inc. <br />PHONE 209-577-4333 <br />CONTRACTOR ADDRESS 1224 6th Street <br />CITYISTATEIZIP <br />Modesto / CA / 95354 <br />SUBCONTRACTORrl I <br />PHONE <br />SUBCONTRACTOR ADDRESS <br />CITYISTATE/ZIP <br />LICENSE I C-57 t I C-61 IID -09 <br />I Qlher <br />NUMBER -46"P4 <br />EXPIRATION DATE 02� <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township _ Range Section <br />NTENDED USE 7 Domes&-JPrivate ❑ Irrigation/Agdwllurel C Industrial 7 Water Quality Monitoring of Sampling/Characterize o <br />3 Public Water System <br />I(dlOerent from Owner. water system Nama convad Nam or Phone I- er <br />TYPE OF WORK 7flew Well 7 R acemenl Well C Well AllerallordModification 7 Other <br />Monitoring Wallis) # of wells D Soil Boring(S) I1 of taxing. r Geolechnical a or Lodnys <br />7 Out -Of -Service Well C Out -Of -Service Well Renewal D Cross -Connection Repair <br />3 New Pump J PumD Reolacement D Pumo Repair D Raise Well Casino <br />Drilling Method 7 Mud Rotary 7 Air Rotary C Auger D Cable Tool 7 Push Point 7 Other <br />Proposed Well Depth 30 R Excavation 6 In diameter D Open Bottom D 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 o Steel E Plastic D Stainless Steel D Other <br />Grout Seal Depth fl JLNeat Cement (94 /b bag/5-10 gat water) D Sand Cement sack mix/7 gal water <br />J Bentonite (20% solids) .J Other <br />Grout Placement Method rumped u Free Fall a Other j Retardant / Accelerator (name) <br />PEDESTAL Installed By D Driller O Pump Contractor J Other <br />7 Concrete Pedestal Dimensions: V'Adth it Length it Thick In D Christy Box D Stove Pipe <br />PUMP J Submersibleu Turbine u Other HP Pump Set ft Standing Water Level _ fl <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 />EPARTMENT US/E_ ONLY U I 1 �} <br />Application Accepted By Data /V ,6--y 7 Area I I `I Employee ID# <br />Grout Inspection By h1nall Dale -10 /(U 1 :?7 SPECIAL Well Permit <br />Pump Inspection By Date WAIVER Received <br />Soil Boring InWWclion By - n Date Cons)ructed Well Depth it ii <br />PE Sc Received Che <br />Codes Info By 16sh <br />Amount <br />Remitted <br />Date PermiU Invoice # Well ID# <br />Service Request # <br />.I�rr <br />sl�-tel" <br />lupi WP �73�53 <br />4 U <br />EMD 43-0S <br />SM410a <br />WELL/PUMP PERMIT <br />ZZ <br />� Z W <br />N OZa <br />lw la z2m <br />U iv (3019 <br />. W H 05F <br />rrzW <br />el <br />�ro Vv <br />\ - <br />ipe / <br />� gckna <br />X <br />00 <br />Irl <br />