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5WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTA�HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED 3�J0��,W6L'7 C- D SI NSG CITY/ZIP JlV—I(�� 1) V J �.�/� > JOB ADDRESS T� m 1 � `, CROSS STREET ��C G t APN t 9 )t u t PARCEL SIZE ..q m LAND USE APPLICATION# A OWNER NAME G�1WIY �I) r 'k-).A, CC( 4� C�(� f PHONE / C/ y OWNER ADDRESS (( `,. �l l�Q l f� CITY/STATE/ZIP S-b �CSI e � CA / Z20 2 CONTRACTOR Kleinfelder PHONE 209-948-1345 CONTRACTORADDRESS 2001 Arch-Airport Rd. Suite 100 CITY/STATE/ZIP Stockton, Ca. 95206 SUBCONTRACTOR All Well Abandenment//�� `` PHONE 9l6. 363. ?_TSSSUBCONTRACTOR ADDRESS n69' //-TZ%r0L1J /Fc aA - —C,,-7c CITY/STATE/ZIP eor&ya l eA.1 LICENSE X C-57 C-61 ❑ D-09 Other NUMBER 6/�3.5EXPIRATION DATE GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural Ci Industrial Water Quality Monitoring C' Soil Sampling/Characterization ❑ Public Water System If different from Owner: Water System Name contact Name or Phone Number TYPE OF WORK ❑ New Well � Replacement Well Well Alteration/Modification Other ❑ Monitoring Well(s) #of wells Soil Boring(s) #of borings Geotechnical #of borings ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal r5 Cross-Connection Repair i New Pump ❑ Pump Replacement Pump Repair ❑ Raise Well Casing PAY WELL CONSTRUCTION fvecEIti/F J Drilling Method.X Mud Rotary ❑ Air Rotary Auger ; Cable Tool -: Push Point i Other Proposed Well Depth'ZO--7p ft Excavation in diameter I Open Bottom Gravel Pack/Gravel Size er G Conductor Casing in diameter / Conductor Casing Depth ft E�eN C0u Well Casing Diameter in Thickness/Gauge/ASTM Sched r' Steel ❑ Plastic ❑ Stainless Steel O1�TNO Grout Seal Depth ft Neat Cement(94 lb bag/5-10 gal water) i I Sand Cement sack mixl7 gRater ❑ Bentonite(20%solids) 4` r-E Grout Placement Method Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) PEDESTAL Installed By ❑ Driller ❑ Pump Contractor I I Other ❑ Concrete Pedestal El Dimensions:Width ft Length ft Thick in ❑ Christy Box Stove Pipe PUMP C Submersible[] Turbine ❑ Other HP Pump Set ft Standing Water Level ft I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. M14 OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL(209)953-7697 SIGNED TITLE j�&icz 11-7a m2,Ye— DATE :�;Z—/(J 4 I I llsi ti.f r .40 Application Accepte By T Date Area 9C Employee ID# C'7� Grout Inspection B Date C SPECIAL Well Permit S� Pump Inspection By Date r / C WAIVER Received ill Spee 'ovlSoil Boring Inspection By C[ Q O O Date Constructed Well Depth ft (0y COMMENTS Fj ,A I b-/ car 0 n 0 A h/ I - pjtQ q/7#/-70 2Z / n/ t4� vol PE SC Received /Check#/ Amount Permit/ Codes Info B Cash Remitted Date Service Request# Invoice# Well ID# EHD12 0` 53ff� WELL/PUMP PERMIT 4/30/12