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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 /> JOB ADDRESS 3263 E. Cherokee Road CITY/ZIP Stockton, 95205 m <br /> �Q D <br /> CROSS STREET North Newton Rd. A�PN 132-07/-06 PARCEL SIZE 8 AcreS LAND USE APPLICATION# <br /> OWNER NAME _[ a�ii�A2L/T I L, (�(� PHONE <br /> OWNER ADDRESS CITYISTATE/ZIP <br /> CONTRACTOR Klelnfelder PHONE 209-948-1345 <br /> CONTRACTOR ADDRESS 2001 Arch Airport Road, Suite 100 CITYISTATE/ZIP Stockton, CA 95206 <br /> SUBCONTRACTOR V&W Drilling PHONE 209-469-7700 <br /> SUBCONTRACTOR ADDRESS 3806 Duck Creek Drive CITY/STATE/ZIP Stockton. CA 95215 <br /> 4/30/2015 LICENSE XC-57720904 57 C-61 D-09 Other NUMBER EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Rango Section <br /> INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring X Soil Sampling/Characterization <br /> Public Water System <br /> If different frorn Owne( Water System a[Tie GonlactNameor ionef,lurribef <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br /> Monitoring Well(s) _ #of wells Soil Boring(s) a of borings X Geotechnical 15 Of of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> _ New Pump Pump Replacement Pump Repair Raise Well Casing <br /> j WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary XAuger Cable Tool Push Point Other <br /> Proposed Well Depth 15 -20 ft Excavation B in diameter Open Bottom r 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 ft Neat Cement(94 lb bag/5-10 gat water) Sand Cement sack mix17 gal water <br /> Bentonite(20%solids) X Other SOI(cuttings <br /> Grout Placement Method Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL. Installed By Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width it Length ft Thick in Christy Box Stove Pipe <br /> i UMP Submersible Turbine Other HP Pump Set it 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 /> C INIML� 14_16f UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED --- � � ^= TITLE Protect Engineer DATE 6/6/2014 <br /> i <br /> l <br /> I <br /> Y <br /> ( <br /> 4 <br /> h' <br /> 88 <br /> i <br /> P - <br /> i <br /> DEPARTMENT USE ONLY <br /> Application Accepted By /l /l`C, Date Area cc' !! Employee ID* � <br /> Grout Inspection By Date S ECIAL Well Permit <br /> Pump Inspection gym Date WAIVER Received <br /> Soil Boring Inspection By r Date �� _ Constructed Well Depth ft <br /> COMMENTS <br /> '> 7��, 1-!n - S Z II r;Gl _ %i'7a: <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By Cash Remitted Service Request# <br /> 00 <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 131134/08 <br />