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p�1�� zv �S►1 I� �I (� <br /> WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 EAST MAIN STREET-STOCKTON CA 96202-(209)466-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> fom <br /> JOB ADDRESS <br /> 3263 E.Cherokee Road CITY/ZIP Stockton,95205 1��0 D <br /> CROSS STREET North Newton Rd. APN 132-07-09 PARCEL SIZE 8 ACreS LAND USE APPLICATION# °a <br /> in <br /> OWNER NAME1^,f/cr.G� 7��Tl�-(J I/l C fes. PHONE <br /> OWNER ADDRESS CITY/STATE/ZIP <br /> CONTRACTOR Kleinfelder - ll•I� PHONE 209-948-1345 <br /> CONTRACTOR ADDRESS 2001 Arch Airport Road,Suite 100 CITY/STATFIZP Stockton,CA 95206 <br /> SUBCONTRACTOR V&W Drilling PHONE 209-469-7700 <br /> SUBCONTRACTOR ADDRESS 3806 Duck Creek Drive CITY/STATEmP Stockton.CA 95215 <br /> LICENSE XC-57 C-61 I D-09 Other NUMBER 720904 EXPIRATION DATE 4/30/2015 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br /> FLENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring y Soil Sampling/Characterization <br /> Public Water System <br /> H different from Owner: Water System Name w me or one um <br /> TYPE OF WORK New Well Replacement Well I Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells Soil Boring(s) 0 of borings X Geotechnical 15 °of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump i 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 1 S-20 it Excavation 6 in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter I Conductor Casing Depth It <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 gal water) Sand Cement sack mix17 gal water <br /> Bentonite(20%solids) XOther SO'ICuttingS <br /> Grout Placement Method - Pumped - Free Fall :Other Retardant I Accelerator(name) <br /> PEDESTAL Installed By Driller IPump Contractor Other <br /> Concrete Pedestal Dimensions:Width it Length It Thick in Christy Box Stove Pipe <br /> PUMP Submersible Turbine Other HP Pump Set It Standing Water Level ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPUCA71ON 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 INIM�ILUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> 6/6/2014 <br /> SIGNED ��- TITLE Protect Enaineer DATE <br /> Y <br /> Hiuf M <br /> A17 <br /> Be t <br /> -777 1 <br /> 99 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By !! ) N a7/i c-I Date 4 41-11- <br /> Area C621 Ol Employee I�°V <br /> Grout Inspection By DateWell Permit <br /> Pump Inspection Date WAIVER Received <br /> Soil Boring Inspection By Dale & �/ Constructed Well Depth It <br /> COMMENTS L -' L - - - �� <br /> rit7lf c'f� 29 Gly-` 0 <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Cash Remitted Service Re uest# <br /> g3l7 1 S 3� �� X200 �g79P <br /> EHD 43-08 WELL/PUMP PERMIT <br /> 8104/08 <br />