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3�1�tI ° <br /> s.•:Fw� 5t�f iia IV�'7r✓` o ) 1b <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> -� S 1 y �"I ?5 1 Vb CITY/7P_ <br /> 'JOS ADDRESS ` '�' t�L. '> <br /> D <br /> CROSS STREET L-1 oNjjVL,; 9-13 APN I PARCEL SIZE 'q LAND USE APPLICATION# ("1.o rm� <br /> OWNER NAME — /f• LI �iyA�� r'1 PHOwNE {'� <br /> OWNER ADDRESS 1-1�� `-1 /L.491./l.l�l�( - CITYISTATEIZIP'��J�'r'Y C/��!'-1 <br /> CONTRACTOR Kleinfelder PHONE 209-948-1345 <br /> CONTRACTOR ADDRESS 2001 Arch-Airport Rd. Suite 100 CITY/STATE/ZIP Stockton, Ca. 95206 <br /> SUBCONTRACTOR V&W Drilling PHONE 209-469-7700 <br /> SUBCONTRACTOR ADDRESS 3806 Duck Creek Dr. CITY/STATFJZIP Stockton, Ca. 95215 <br /> LICENSE X C-57 C-61 1 0-09 Other NUMBER 720904 EXPIRATION DATE 4/3 0/2 01 g <br /> GEOGRAPHICAL INFORMATION: Coordinates Y Township_ Range Section_ <br /> INTENDED USE 1 DomesticlPdvate Inigation/Agricultural Industrial i Water Quality Monitoring 'xSoil SamplinglCharacterization <br /> I.Public Water System <br /> If different from Owner: vvwel bpierri Name Contact Name or PhoM N.ffmer <br /> TYPE OF WORK 1 New Well ; Replacement Well Well Alteration/Modification Other <br /> I Monitoring Well(s) #of wells Soil Boring(s) •of borings Geotechnical��#of benne° <br /> I Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method)(Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Well DepthI- _ <br /> �-W it Excavation�_in diameter Open Bottom ;Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter I Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/GaugeIASTM Sched Steel Plastic Stainless Steel Other <br /> Grout Seal Depth 'ZO it `Meat Cement(94 lb bag/5-f0 gal water) Sand Cement sack mix17 gal water <br /> Bentonite(20%solids) <br /> Grout Placement Method Pumped Free Fall XOther Retardant I Accelerator(name) <br /> �PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal !Dimensions:Width_ft Length It Thick in Christy Box Stove Pipe <br /> PUMP 1 Submersible I Turbine Other HP Pump Set ft Standing Water Level h <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. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 4 HO R/�yWANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED `±'t� /.C1diE2� TITLE J JOaj:'L �'iL'•/f`D.t DATE <br /> �q4 <br /> ^f <br /> as <br /> M1� r+.erla'_�I� ' <br /> 3 <br /> vs <br /> DEPARTMENT U E N L Y <br /> Application Accepted By Date Area Employee ID#-�L1�IUfitx�/� <br /> Grout Inspection By Date C SPECIAL Well Per PAYIWENT <br /> Pump Inspection By Date WAIVER ReceiveIRECEIVEp <br /> Soil Boring Inspection 8 , Date Constructed Well Depth_ t< <br /> COMM NTS <br /> G <br /> tuyu <br /> �/ rfa�r a �. r 2 Fe G✓/�iFte^...... -,1OIISff <br /> PE SC Received Check#/ AmountDatePermit/ hlvotce�LAt M OE <br /> Codes Info B Cash Remitted Service R uest Sayr <br /> G e, `6110110 Z00-76LN <br /> +"CN3 `2- <br /> EHO 43-9 WELL PUMP PERMIT <br /> 4r"12 <br />