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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAMILTON AVENUE-STOCKTON CA 95205-(209)4683420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPI ES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 1 Zin rFe ///��� + CrrY/zP / ✓ Z T [�D7 <br /> CROSS STREET �a1k ��/C� a APN O ` LO ��/7 PARCEL SIZE r/��LAND USE APPLICATION# �$a <br /> -PrOWNER NAME PHONE e1 <br /> OWNER ADDRESS CRY/STATE/ZIP <br /> CONTRACTOR Kleinfelder PHONE (209)948-1345 <br /> CONTRACTOR ADDRESS 2001 Arch Airport Road,Suite#100 CrfY/STATE/7JP Stockton/CA/95206 <br /> ffnnDri <br /> SUBCONTRACTOR IC t // PHONE <br /> SUBCONTRACTOR ADDRESS u CRY/37ATE/ P <br /> LICENSE JC-57 ❑C-61 ❑D-09 ❑Other NUMBER ' (Z�I`_4 EXPIRATION DATE qwzoza <br /> DOMESTIC WELL SAMPLING:-General Mineral/Coliform Bacteria(4391)7 Dibromochloropropane(4392)7 Arsenic(4393) <br /> INTENDED USE ❑DomesticlPrivate ❑Inigation/Agricultural ❑Industrial ❑Water Quality Monitoring Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Owner. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> D Monitoring Well(s) #of wells ❑Sal Boring(S) #of borings Geotechnical_S #of borings <br /> ❑Out-OfService Well 7 Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ❑New Pum ❑Pump Replacement 7 Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method I Mud Rotary ❑Air Rotary Al Auger ❑Cable Tool ❑Push Point ❑ Other <br /> Proposed Well Depth S-30 ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thic ness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth ft /Neat Cement(94 lb bagl5-10 gal water) ❑Sand Cement Sack mur/7 gal water <br /> ❑Bentonite(20%solids) ❑Other <br /> Grout Placement Method Y Pumped 26 Free Fall ❑Other ❑Retardant I Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> ❑Concrete Pedestal❑Dimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP ❑Submersibleo 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 /> MINIMUM 24 HO AD CE NOTICE REQUIRED FOR SP(E TIONS-PLEASE CALL(209)95 -769 <br /> SIGNED (//! V L TITLE ✓ T-. �VI�)�/1C.1'iI DATE <br /> EENr <br /> 1VED <br /> 5 2019 <br /> UJ <br /> ° IN COU <br /> 1Y <br /> �TMENT <br /> DEPARTMENT USE ONLY Ayn <br /> Applicaton Accepted By Data3 S V1 Area / 1 Employee ID# �H L •//��/1 <br /> `r'ek'7 <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date D WAIVER Received <br /> Soil Boring Ins 'on By Data 0 Constructed Well Depth ft <br /> COMMENTS 1 <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By Cas Remitted Service Re uest# <br /> 2S <br /> � b <br /> EHD 4306 8101116 WELL/PUMP PERMIT <br />