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�"" 2vISI11� Col (4 <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 EAST MAIN STREET-STOCKTON CA 95202-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> La <br /> JOB ADDRESS 3263 E.Cherokee Road CITY/ZIP Stockton,95205 <br /> CROSS STREET North Ne/wton Rd. APN 132-07-09 PARCEL SIZE 8 ACreS LAND USE APPLICATION# <br /> OWNER NAME fa",d" / P' pAtLn(//d— PHONE <br /> OWNER ADDRESS CITY/STATE/ZIP <br /> CONTRACTOR Kleinfelder !2(p - 22-' PHONE 209-948-1345 <br /> CONTRACTOR ADDRESS 2001 Arch Airport Road,Suite 100 CITY/STATE/LP Stockton,CA 95206 <br /> SUBCONTRACTOR VSW Drilling PHONE 209-469-7700 <br /> SUBCONTRACTOR ADDRESS 3806 Duck Creek Drive CITYISTATE/ZIP Stockton CA 95215 <br /> LICENSE XC-57 C-61 D-09 Other NUMBER 720904 EXPIRATION DATE 4/30/2015 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section_ <br /> INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring X Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner W.er SYV..N,ime Contact Name or Phone Number <br /> TYPE OF WORK New Well Replacement Well Well Alteration(Modihcalion Other <br /> Monitoring Well(s) #of wells Soil Boring(s) #of oonngs X Geotechnical 15 of Iwrmps <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary XAuger Cable Tool Push Point Other <br /> Proposed Well Depth 15-2n ft Excavation R 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 Schetl Steel Plastic Stainless Steel Other <br /> Grout Seal Depth ft Neat Cement(94/b bag/5-10 gal water) Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) XOtherSoitc ILttlnOS - <br /> Grout Placement Method Pumped Free Fall Other Retardant/Accelerator(name) <br /> IPEDESTAL Installed By Driller Pump Contractor Other <br /> L 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. q� <br /> <Z-- INIMI} UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED \'''"FFFFFL,� TITLE Project Engineer DATE 6/6/2014 <br /> i <br /> Y <br /> ti \' <br /> 4 <br /> T <br /> 66 � - <br /> �C' <br /> DEPARTMENT USE ONLY �� <br /> Application Accepted By //? /✓F;9/3-LT Dale , / Area b Employee I <br /> Grout Inspection By Date r S6CIAL Well Permit <br /> Pump InspectionDate WAIVER Received <br /> Soil Boring Inspection By Date 21 Constructed Well Depth ft <br /> COMMENTS ZD <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Cash Remitted Service Request# <br /> L312 l Sb pr:- 3� �� -520o 6g 79P <br /> EHD 47-06 WELL/PUMP PERMIT <br /> P10410a <br />