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2 0V OAR) • ool A� <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISS1117-171 <br />JOB ADDRESS ZS oo_I�`J,�I��� Ok CITY/ZIP J� oC-LL 1IDL/ � 9 S (_ ✓ 6 <br />CROSS STREETT ) I L L 7Wt S APN t �� � � O� � PARCEL SIZELAND USE APPLICATION # <br />OWNER NAME11 S PHONE !137- U ¢ <br />ya_D <br />OWNER ADDRESS `� CITY/STATE/ZIP 3 hy_k) CA <br />CONTRACTOR Kleinfelder PHONE 209-948-1345 <br />CONTRACTOR ADDRESS 2001 Arch -Airport Rd. Suite 100 CITY/STATE/ZIP Stockton, Ca . 95206 <br />SUBCONTRACTOR T 1 o I)r-zl ling PHONE Q1iS — 3� 1— 2 2 3 4 <br />SUBCONTRACTOR ADDRESS 5�6 �V2S An CITY/STATE/ZIP �c�r YSIY1Prltn CA Q-ir(a1 <br />LICENSE X C-57 I I C-61 I I D-09 I Other NUMBER -109Z-7 EXPIRATION DATE 9/ 3oz l b <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br />INTENDED USE I Domestic/Private I I Irrigation/Agricultural I I Industrial ❑ Water Quality Monitoring IXSoil Sampling/Characterization <br />I Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK FI New Well I 1 Replacement Well I I Well Alteration/Modification ❑ Other <br />I I Monitoring Well(s) # of wells 1-1 Soil Boring(s) # of borings ),(Geotechnical of borings <br />n Out -Of -Service Well I I Out -Of -Service Well Renewal I I Cross -Connection Repair <br />I I New Pump I I Pump Replacement I_I Pump Repair I I Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method ❑ Mud Rotary 1_I Air Rotary -•.0PI11IIII I I Cable Tool iPush Point ❑ Other <br />Proposed Well Depth5(J-- 160 ft Excavation, in diameter a Open Bottom I Gravel Pack/Gravel Size in diameter <br />I I Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diamete in Thickness/Gauge/ASTM Sched C1 Steel n Plastic LI Stainless Steel 1-I Other <br />Grout Seal Depth�ft X Neat Cement (94 lb bag/5-10 gal water) Ci Sand Cement sack mix/7 gal water <br />17 Bentonite (20% solids) CI Other <br />Grout Placement Method Y,Pumped LI Free Fall n Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By I I Driller 1-1 Pump Contractor I- Other <br />Concrete Pedestal IjDimensions: Width ft Length ft Thick in I I Christy Box Stove Pipe <br />PUMP n Submersible( I Turbine i Other HP Pump Set ft Standing Water Level ft <br />W <br />m <br />D <br />0 <br />0 <br />m <br />r <br />■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ <br />Received <br />By <br />(Check#/ <br />Cash <br />Amount <br />Remitted <br />Date <br />Permit( <br />Service Re uest # <br />Invoice# <br />WellID# <br />■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ <br />■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ <br />■■■■■■■■■■■■■ ■■ ■ ■■■■■■■■■■■■■■■■■■ <br />0 <br />O6, <br />.:. a... ' .. <br />.. <br />PE <br />Codes <br />Sc <br />Info <br />Received <br />By <br />(Check#/ <br />Cash <br />Amount <br />Remitted <br />Date <br />Permit( <br />Service Re uest # <br />Invoice# <br />WellID# <br />0 <br />O6, <br />EHD 43-06 WELL /PUMP PERMIT <br />4/30/12 <br />