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WELL/PUMP PERMIT P SAN JOAQUIN COUNTY ENVIRONMENTAL 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 JOB ADDRESS ' S`Ur0 l'VA%'Y �� CITY/ZIP 7�L L, f✓J 4 f� L7 m 77 -7 p / r O CROSS STREET I.L`l� l�t.�J�5 APN (/l 7 7V Q� PARCEL SIZE�'�l�16 LAND USE APPLICATION# rn OWNER NAMEC I L2 Ci�11f Ci (C`�C7T� PHONE I 3-7 OWNER ADDRESS Li-Z �T �Z P�iLPsbC� CITY/STATE/ZIP A 2_ CONTRACTOR Kleinfelder PHONE 209-948-1345 CONTRACTOR ADDRESS 2001 Arch-Airport Rd. Suite 100 CITY/STATE/ZIP Stockton, Ca. 95206 SUBCONTRACTOR V&W Drilling PHONE 209-469-7700 SUBCONTRACTOR ADDRESS 3806 Duck Creek Dr. CITY/STATE/ZIP Stockton, Ca. 95215 LICENSE X C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER 720904 EXPIRATION DATE / 0 /7 n 1 R GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring 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 ❑I Soil Boring(s) #of borings `Geotechnical#of borings Li Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair ❑ New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION Drilling Method ❑ Mud Rotary ❑ Air Rotary XAuger ❑ Cable Tool ❑ Push Point ❑ Other Proposed Well Depth I(2 - c-0 ft Excavation 6o in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter ❑ Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter_ in Thickness/Gauge/ASTM Sched 11Steel 11Plastic ❑ Stainless Steel ❑ Other Grout Seal Depth 50 ft X Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water ❑ Bentonite(20%solids) ❑ Other Grout Placement Method XPumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other ❑ Concrete Pedestal ❑Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe PUMP ❑ 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. MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209953-7697 /� (,-Pica &� SIGNED '4-�— ti� TITLE F9S0C,f0A, 6��t;C4%4 1i DATE NORTHERN � N.w car La 1 2 %'4'547 ------------- - -- ,r - 1 (� /��(r.I Na„M kRT"`VH�a tllft4t. B. i+9^1F ax rS _� r� !UD A'T78 A, \ a 90151. -c ` CITYOF N 3 p F 9TOONTON •, Lev T erseLM ee.1e 09.NET 4 H W 2 3 4 5 a��a .... EbiaamW 00 t + 4y�X s a tlin tlADantlonetl—� Rasa. .3os a sroc roN 6 crrycounm� 61 M U G C H R I M C m U J C v IV L�1 Application Accepted By Date 7 Area Employee ID# Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received of I Soil Boring Inspection By to/d,31-�?O/ Constructed Well Depth ft COMMENTS PEAnf Received Check#/ Amount Date Permit/ Invoice# Well ID# Codes B rAL Cash Remitted Service Request# X37 � 0 0-14 -T L4 � 10--)LO-0 �Ij P 00.31` b l EHD 43-06 WELL/PUMP PERMIT 4130/12