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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 55205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> y <br /> JOB ADDRESS Median of 1-5 F�, _1 CITY/ZIP south of Gait,95632 <br /> CROSS STREET Levee Road APN QC PARCEL SIZE LAND USE APPLICATION# m <br /> N <br /> OWNER NAME Public Right of Way PHONE N <br /> OWNER ADDRESS NA CITYISTATE/ZIP <br /> CONTRACTOR Kleinfelder PHONE 916-366-1701 <br /> CONTRACTOR ADDRESS 3077 Fite Circle CITY/STATE/ZIP Sacramento,CA 95827 <br /> SUBCONTRACTORKleinfelder PHONE 916-366-1701 <br /> SUBCONTRACTOR ADDRESS 3077 Fite Circle CITY/STATE/ZIP Sacramento,CA 95827 <br /> LICENSE , C-57 C-61 D-09 Other NUMBER 467252 EXPIRATION DATE 12)31)14 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section_ <br /> INTENDED USE DomestiGPrivate Irrigation/Agricultural Industrial Water Quality Monitoring V Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner. W.I.,Sy.t.m Name ac ame or ne umber <br /> TYPE OF WORK New Well Replacement Well Well Aiteration/Modification Other <br /> Monitoring Well(s) #of wells Soil Boring(s) itofb—p eGeotechnical 2 Auf borings <br /> 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 V Mud Rotary Air Rotary Auger Cable Tool Push Point V Other CPT <br /> Proposed Well Depth It Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad Steel Plastic Stainless Steel Other <br /> Grout Seal Depth 175 ` ft Neat Cement(94/b bag(5-10 gal water) Sand Cement sack m/x/7 gal water <br /> Bentonitlids) Other <br /> Grout Placement Method Pumped Free Fall p other Tremie Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width ft Length ft Thick in Christy Box Stove Pipe <br /> PUMP Submersible Turbine Other HP Pump Set ft Standing Water Level ft <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. 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 /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED_ -'"�-- TITLE Geologist DATE 4/25114 <br /> NT <br /> ED <br /> 2014 <br /> E LL <br /> �°AL <br /> T'' <br /> TMENT <br /> DEPARTMENT USE ONLY / �- <br /> Application Accepted By N ��� Date Zts /� Area M4- 'i Employee ID# L-SLI:LW <br /> Grout Inspection By Date L SPECIAL Well Permit <br /> Pump Inspection B to L WAIVER Received <br /> Soil Boring I ton DateE �1/ ///�/ Constructed Well Depth It <br /> G <br /> PE SC RemlveS Check#/ Amount Permit/ <br /> Codes Info B 1/ Cash Remitted Date Service Request# Invoice# Well ID# <br /> �� Y 1� 09� 4129b5 el 0 12el Z <br /> D <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4/30112 <br />