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WELUPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AvENuE-STOCKTON CA 95205 • (209) 4683420 <br />NON-REFUNDABLE PERMIT ;ALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS l/ 9 1 9Y1)14 <br />CROSS STREET 1-. <br />OWNER NAME <br />OWNER ADDRESS jS J l� <br />CONTRACTOR Kleinfelder <br />CRT21P <br />PARCEL <br />/SIIZE�r 1 LAND USE APPLICATION # <br />`PHONE <br />CRYISTATEIZIP <br />PHONE (209)948-1345 <br />CONTRACTOR ADDRESS 2001 Arch Airport Road, Suite #100 crryISTATE Zp Stockton/ CA/ 95206 <br />SUBCONTRACTOR V j/'! ,1+Y.) �i , ��✓fi,C�� }I� ��P�7NDJNE2(2c��t)/A,zIG <br />SUBCONTRACTOR ADDRESS 1 1 J�Z JZR Irrl L to 1 .� I %^ Cn�Y/STATEl7P <br />FA"r Hit / L raj <br />LICENSE C-57 n G-61 n D-09 n Other % <br />_ NUMBER `O C " J�EXPIRATION DATE <br />DOMESTIC WELL SAMPLING: - General Mineral/Coliform Bacteria (4391) ' Dibromochloropropane (4392) - Arsenic (4393) <br />7 %) <br />INTENDED USE n Domestic/Private n IRigatiordAgricultural n Industrial 0 Water Quality Monitoring % Soil Sampling/Characterization <br />n Public Water System <br />If di ferunt from Owner. Water byatem Name Contact Name or Phone Number <br />TYPE OF WORK -1 New Well D Replacement Well n Well Alteration/Modification n Other <br />n Monitoring Well(s) # of wells rl Sol[ Boring(s) # of borings NGeotechnical ];� # of borings <br />n Out -Of -Service Well 0 Out -Of -Service Well Renewal 7 Cross-Connectlon Repair <br />Drilling Method 'N Mudd RotaryI^� n Air Rotary \ Auger 0 Cable Tool -1 Push Point n Other <br />;/ •-Q <br />Proposed Well Depthyit Excavation In diameter 11 Open Bottom 7 Gravel Pack/Gravel Size in diameter <br />Q Conductor Casing In diameter / Conductor Casing Depth ft <br />Well Casing Diameter_ In ThidmesslGaugelASTM Sched D Steel 0 Plastic 0 Stainless Steel 0 Other <br />Grout Seal Depth ft 'St Neat Cement (94 lb bag/5-10 gal water) -] Sand Cement sack mcd7 gal water <br />.-I Bentonite (20% solids) 7 Other <br />Grout Placement Method 11Q Pumped 0 Free Fall 0 Other n Retardant I Accelerator (name) <br />PEDESTAL Installed By rJ Driller 0 Pump Contractor n Other <br />❑ Concrete Pedestal DDlmenslons: Width _ft Length ft Thick In 0 Christy Box :]Stove <br />Pipe <br />PUMP ❑ Submersibles Turbine n 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 HO ADVANCE NOTICE REQUIRED FO(R� INS CTIOIN 1Sn-PLEASE CALL <br />PLEASECALL (209) 953-76797 <br />SIGNED_ U11A— TITLE �] %U Tom. /�' ("IJYJ�CJ DATE <br />-�l 1 <br />D"-ARTMENT U E ONLY <br />Application Accepted By / ,1 Date /0 Z �Area Employee ID# <br />Grout Inspection By - Date U SPECIAL Well Permit <br />Pump Inspection By ? Date U WAIVER Received <br />� <br />Soil Boring Inspection By � l Date Constructed Well Depth ft <br />COMMENTS <br />Il VEFO <br />20 18 <br />PE SC Received <br />Codes Info <br />Check## <br />C sh <br />Amount Date <br />Remitted <br />Permit/ Invoice# WeIIID# <br />SeryRa uest # <br />ice <br />EHO43.06 8,01116 <br />WELL (PUMP PERMIT <br />