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vU 3 <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 EAST MAIN STREET-STOCKTON CA 85202 . (209) 468.3420 <br />NON-REFUNDABLE MIT <br />CALL 209 953-7697 FOR INSPECTIONS <br />EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 2I 7 26982 Nowell Rd <br />CI /ZIP <br />Thornton / 95686 <br />CROSS STREET N. New Hope Rd <br />APJ.��001-23`0-02 41 <br />PARCEL SIZE - <br />LAND USE APPLICATION# <br />o m C� ( <br />I" J <br />Pump Inspection By <br />Date <br />OWNER NAME ' ` J <br />7s f <br />Soil Boring Inspection By <br />COMMENTS &Id (�G%e' <br />PHONE �/1 <br />OWNER ADDRESS <br />11 / <br />"J`C6 / <br />I_ L V' I C S Z y 2 <br />CONTRACTOR Kleinfelder, Inc <br />pp <br />�t—(1C �� <br />//C��ITYISTATEITJP <br />15 -�`f'� <br />PHONE 209-577-4333 <br />CONTRACTOR ADDRESS 1224 6th Street <br />crryiSTATE12.iP <br />Modesto / CA / 95354 <br />SUBCONTRACTOR a er <br />PHONE gTe-974-9to-r <br />SUBCONTRACTOR ADDRESS <br />CITY/STATEIZIP <br />LV21 <br />--.2,i} it l <br />LICENSE C-57 C-61 D-09 <br />Other <br />NUMBER <br />E EXPIRATION DATE' 'o'" <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br />NTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring oI Sampling/Characteriza to <br />Public Water System <br />If different from w-,.. a er syt.. ame Contact NameEFVhome Number <br />TYPE OF WORK New Well Repl cement Well Well Alteration/Modification Other <br />MonitoringWell(s)#of wells SoilBodng(s) #.(borings Geotechnical _2"')#ofboring. <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />Drilling Method <jjud Rota Air Rotary (EE)Cable Tool Push Point Other <br />Proposed Well Depth 30 & 50 ft Excavation 6 In diameter Open Bottom Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Weli Casing Diameter _ In Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br />Grout Seal Depth ft # Neat Cement (94/b bag15-10 gal water) Sand Cement sack mixf7 gal water <br />Bentonite (20% so ids) Other <br />Grout Placement Method gL00uMp6ed_3 Free Fall Other Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor Other <br />Concrete Pedestal Dimensions: Width it Length R Thick in Christy Box Stove Pipe <br />PUMP Submersible Turbine Other HP Pump Set it Standing Water Level it <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 />MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br />SIGNED <br />a <br />0 <br />T <br />N <br />Z <br />w <br />N k -j <br />d00 <br />�z <br />� <br />zQw� <br />Cl) = <br />PE SC Received CWW1 Amount Date <br />Codes Info B ash Remitted <br />DEPARTMENT USE ONLY <br />- <br />�i <br />7 q <br />Applicatlon Accepted By <br />Date <br />Area Employee ION <br />Grout Inspection By <br />Date %� r/ <br />SPECIAL Well Permit <br />Pump Inspection By <br />Date <br />WAIVER Received <br />Soil Boring Inspection By <br />COMMENTS &Id (�G%e' <br />Dale // <br />�� / I `r�_r <br />QCConnstrucrt�ed ,W�ell DDeptth� <br />1 �� <br />11 / <br />"J`C6 / <br />d� •�� r <br />`7 <br />PE SC Received CWW1 Amount Date <br />Codes Info B ash Remitted <br />Permit/ Invoice # Well ID# <br />Service Re uest# <br />143 7), 1S .NlC <br />tLL- <br />3 <br />END 99-08 <br />8!04108 <br />WELL /PUMP PERMIT <br />