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WELL/PUMP PERMIT <br />v SAN JOAQUIN COUNTY ENW RONMENTAL HEALTH DEPARTMENT 600 EAST MAIN STREET - STOCKTON CA 96202 - (209) 4603420 <br />JOB ADDRESS <br />26901 N. Nowell Rd. CITYI Thornton / 95686 <br />CROSS STREET N. Nowell Rd <br />A - 001-230-27 ARCELSIZE 31'36 LAND USE APPLICATION# <br />OWNERNAME <br />J CO J N.ST PHONE <br />`1311 <br />A ( <br />l r <br />OWNERADDRESB <br />2tp �—/ r CITYSTATE/21P rl <br />CONTRACTOR Kleinfelder, Inc. <br />PHONE 209-577-4333 <br />CONTRACTOR ADDRESS 1224 6th Street <br />CITY/STATE/ZIP Modesto / CA /95354 <br />SUBCONTRACTOR ` '�MM7r <br />PHONE <br />SUBCONTRACTOR ADDRESS <br />CITY/STATE21P WL1 <br />LICENSE07 G-61 D-09 <br />Other NUMBER 4mg2,-V47)`5-hXPIRATION DATE <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br />NTENDED USE DomesticlPdvate Irrigation/Agricultural Industrial Water Quality Monitoring II S <br />Public Water System <br />If different from Owner. Water System Name Contact Name or one um er <br />TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br />Monitoring Well(s) I # of wells Soil Bodng(s) of borings �r Geotechnical n orborings <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />Drilling Method ud Rota Air Rotary u er Cable Toot Push Point Other <br />Proposed Well Depth 30&50 it 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 ale Neat Cement (94 Ib bag/5-10 gal water) Sand Cement.__.,,. ... _,...... ... _... sack mix77 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 ft Length it Thick in Christy Box Stove Pipe <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 />!^ <br />MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br />SIGNED j A.iYif TITLE Project Engineer DATE 1012117 <br />PARTMENT USE ONLY CC�� <br />Application Accepted By Date /O ' Areae Employee ID# Y <br />Grout Inspection By Data IN SPECIAL Well Permit J <br />Pump Inspection By Date - y WAIVER Received <br />Soil Boring Inspection By Date r Constructed Well Depth ft <br />PE <br />Codes <br />SC Received Ch #/ <br />Info By Xash <br />Amount <br />Remitted <br />Date Permit/ Invoice # Well ID# <br />Service Re uest# <br />1312- <br />ISO <br />`1311 <br />I� 7 LJ P ixa- ' .7 <br />t d <br />G1 <br />EHD 47-08 WELL /PUMP PERMIT <br />8104108 <br />::)QW <br />LLJ C= oz <br />UW <br />VCS 2 _ <br />W 000 <br />U ¢[c <br />OZ_J <br />_ �wa <br />LL) <br />Cn -T <br />