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ynih�l Scup <br /> WELL/PUMP PERMIT <br /> • „ • SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205-6232-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> to <br /> JOB ADDRESS 21120 EI Rancho Rd cITYmP Tragy,95304 <br /> D <br /> CROSS STREET S of Canal Blvd APN 213-180-25 PARCEL SIZE6--KLAND USE APPLICATION# <br /> m <br /> OWNER NAME Tony Silva_)� �'(' PHONE 209-649-8800 <br /> OWNER ADDRESS 21120 EI Rancho Rd CITY/STATE/ZIP Tracy,CA 95304 <br /> CONTRACTOR Hennings Bros. Drilling CO., Inc. PHONE 209-545-1185 <br /> CONTRACTOR ADDRESS 1930 Ladd Rd CITY/STATE/ZIP Modesto,CA 95356 <br /> SUBCONTRACTOR PHONE <br /> i <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE X C-57 C-61 D-09 Other NUMBER 290813 EXPIRATION DATE 05-31-2018 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section <br /> INTENDED USE XDomestic/Private CI Irrigation/Agricultural 1, Industrial J Water Quality Monitoring t Sail Sampling/Characterization <br /> 1 Public Water System <br /> If different from Owner: Water System Name on a ame or one um er <br /> TYPE OF WORK XNew Well 1:Replacement Well I Well Alteration/Modification -1 Other <br /> Monitoring Well(s) #of wells i=i Soil Boring(s) #of borings I_ Geotechnical #of borings <br /> Out-Of-Service Well C Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pum -�Pump Replacement i 1 Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method X Mud Rotary i Air Rotary Auger Cable Tool G Push Point - Other <br /> Proposed Well Depth 200 ft Excavation 14 in diameter 0 Open Bottom X Gravel Pack/Gravel Size No.6 in diameter <br /> Conductor Casing in diameter ! Conductor Casing Depth ft Sand pack <br /> Well Casing Diameter 8 in Thickness/Gauge/ASTM Sched SDR26 il Steel XPlastic I I Stainless Steel 0 Other <br /> Grout Seal Depth inn ft n Neat Cement(94 Ib bag/5-10 gal water) 1.1 Sand Cement sack mix/7 gal water <br /> X Bentonite(20%solids) Other <br /> Grout Placement Method X Pumped Free Fall Other Retardant!Accelerator(name) <br /> PEDESTAL Installed By 11 Driller X Pump Contractor 0 Other <br /> Concrete Pedestal Dimensions:Width It Length It Thick in -Christy Box -Stove Pipe <br /> PUMP i Submersible:..Turbine G 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 /> MIMUM 24 HOUR ADVANCE Nd &A l ED FO'((yj�INSPECTIONS �f <br /> SIGNED TITL l • DATE L -A-177 <br /> DE ARTMENT USE ONLY <br /> Application Accepted By Date Are. Employee ID# <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Recely? <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> CoPENTS y-1.1 01 b, S b?A ens 41- <br /> -fur <br /> c-fur I;af/ vn U <br /> PE SC ReceivedCheck#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B 2 � Remitted Service Re uest# <br /> J <br /> EH D 43-06 WELL/PUMP PERMIT <br /> 8/04!08 <br />