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f 3 <br /> I <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)466-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS v ' `� u V l CLTYIZIP ��' f-i C.�/ m <br /> n <br /> CROSS STREET)—I NCVl� ti-L! APN `L S� 7 f) Z'' PARCEL SIZE LAND USE APPLICATION# o <br /> A <br /> m <br /> N <br /> OWNER NAME 1`•^hPHONE /K� S <br /> 39 <br /> OWNER ADDRESS L( ✓ CITYISTATEIZIP L / <br /> CONTRACTOR Kleinfelder PHONE 209-948-1345 <br /> CONTRACTOR ADDRESS 2001 Arch-Airport Rd. Suite 100 CITYISTATEIZIPStockton, Ca. 95206 <br /> SUBCONTRACTOR V&W Drillinq PHONE 209-469-7700 <br /> SUBCONTRACTOR ADDRESS 3806 Duck Creek Dr. CITYISTATEIZIP StOcktOn, Ca. 95215 <br /> LICENSE X 0-57 I C-61 D-09 I i Other NUMBER 720904 ExPIRATIoN DATE 4/30/201(9 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE Domestic/Private i Irrigation/Agricultural I I Industrial I Water Quality Monitoring KSoil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone NumIner <br /> TYPE OF WORK 'i New Well i Replacement Well I Weil Alteration/Modification . Other <br /> I Monitoring Well(s) #of wells 1.1 Soil Boring(s) *of borings 'X Geotechnical (�2 #of borings <br /> I Out Of-Service Well a Out-Of-Service Well Renewal H Cross-Connection Repair <br /> New Pump I I Pump Replacement i Pump Repair Raise Well Casin <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary Auger n Cable Tool Push Point I Other <br /> Proposed Well Depth–Up ft Excavation -& in diameter I Open Bottom _I Gravel Pack./Gravel Size in diameter <br /> Conductor Casing in diameter 1 Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched I Steet I Plastic I I Stainless Steel Other <br /> Grout Seal Depth ft �K Neat Cement(94 lb bag/5-10 gal water) I Sand Cement sack mix17 gal water <br /> I Bentonite(20%solids) , .. <br /> Grout Placement Method I Pumped L' Free Fall 'Other 11 Retardant 1 Accelerator(name) <br /> PEDESTAL Installed By I Driller I Pump Contractor Other <br /> u Concrete Pedestal 'Dimensions:Width ft Length ft Thick in I Christy Box I Stove Pipe <br /> PUMP ❑ Submersible Turbine Other HP Pump Set ft Standing Water Level ft <br /> I HEREBY CERTIFY THAT l 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 /> M;1NMlN1NFU&4��H O R, 0VANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br /> $IGNE❑ /G�Q*?@� TITLE i j l7t DATE <br /> 1!Ill. <br /> Nj <br /> 41 <br /> � 1t` Ia , <br /> DEPARTMENT U ENLY <br /> f � c <br /> Application Accepted By Date L� �_ <br /> Area Employee ID# <br /> Grout Inspection By Date L. SPECIAL Well PerF%YMEN,r <br /> Pump Inspection By Date I_ WAIVER ReCeiVeIRECEIVEA <br /> Soil Boring Inspection By, ,pate Constructed Well Depth Lift <br /> COMMENTS �a, <br /> SAN nA <br /> PE SC Received Check#I Amount Date Permit/ invoiceblEi H DE <br /> Codes Info By Cash Remitted Service Reg uest# <br /> WELL IPUMP PERMIT <br /> EHD 43-06 <br /> 4130/12 <br />