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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 />NON-REFUNDABLE PERMIT <br />L:ALL (ZU9) 953-769! FOR INSPECTIONS <br />tAPIKtb 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 26180 N. Nowell Rd <br />CITY/ZIP <br />Thornton / 95686 <br />CROSS STREET N. New Hope Rd <br />APN 001-230-21 <br />PARCEL SIZE 23.3 <br />LAND USE APPLICATION # <br />OWNER NAME <br />PHONE <br />OWNER ADDRESS <br />CITY/STATE/ZIP <br />CONTRACTOR Kleinfelder,Inc. <br />PHONE 209-577-4333 <br />CONTRACTOR ADDRESS 1224 6th Street <br />CITY/STATE/ZIP <br />Modesto / CA / 95354 <br />SUBCONTRACTOR Taber Drilling <br />PHONE 916-371-8234 <br />SUBCONTRACTOR ADDRESS 536 Galveston <br />Street <br />CITY/STATE/ZIP <br />West Sacramento / CA / 95691 <br />LICENSE C-57 If C-61 I D-09 <br />Other <br />NUMBER 969927 <br />EXPIRATION DATE 02/28/2018 <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br />INTENDED USE .1 Domestic/Privale I.I Irrigation/Agricullural Industrial Water Quality Monitoring .. ail Sampling/Characterizatlo <br />7 Public Water System <br />It differ -1 Irom Ovmec R.er SyM.m ame on ac arno .1mne N ­ bel <br />TYPE OF WORK --INew Well ❑ Replacement Well Well Alteration/Modification Other <br />)dMonitoring Well(s)�_ # of wells C Soil Boringp of oanngs s) I Geotechnical �#e* 9 of 6onngs <br />7 Out -Of -Service Well L Out -Of -Service Well Renewal I i Cross -Connection Repair <br />Drilling Method 7 Mud Rotary I Air Rotary i - Auger f I Cable Tool :I Push Point i Other <br />Proposed Well Depth 30 ft Excavation 6 in diameter I; Open Bottom I I Gravel Pack/Gravel Size in diameter <br />I Conductor Casing in diameter / Conductor Casing Depth fl <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched O Steel L Plastic I I Stainless Steel I I Other <br />Grout Seal Depth it Neat Cement (94 Ih hag/5-10 gal water) i I Sand Cement sack mix/7 gal water <br />I Bentonile(20% solids) Other <br />Grout Placement Method , I Pumped I I Free Fall Other Retardant I Accelerator (name) <br />PEDESTAL Installed By U Driller i., Pump Contractor I.1 Other <br />1 Concrete Pedestal Dimensions: Width ft Length ft Thick in I I Christy Box I Stove Pipe <br />U mp 7 Submersible! I Turbine 01her HP Pump Set fl Slanding 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 />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 />Dale <br />Dale <br />Date <br />Area Employee ID# <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth It <br />PE SC Received <br />Codes Info By <br />Clleck#/ Amount Permit/ <br />Cash Remitted Date Service Raquest # Invoice # Well ID# <br />b'PW373BSS <br />EMD 43-M WELL rPUMP PERMIT <br />8/04/06 <br />