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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 /> rn <br /> JOB ADDRESS 21120 EI Rancho Rd CITY/ZIP T[agy,95304 D <br /> CROSS STREET S of Canal Blvd APN 213-180-25 PARCEL SIZELf-Voll-AND USE APPLICATION III <br /> H <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 /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE X C-57 I I C-61 II D-09 I Other NUMBER 29813 EXPIRATIONDATE_05-31-2018 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section_ <br /> INTENDED USE XDomestic/Privale 0 irrigation/Agricultural C Industrial 7 Water Quality Monitoring 7 Sail Sampling/Characterization <br /> 7 Public Water System <br /> V different from Owner: Water System Name one eme or one um er <br /> TYPE OF WORK New Well 0 Replacement Well C Well Alteration/Modification 7 Other <br /> 7 Monitoring Well(s) #of wells D Sob Boring(s) *of borings C Geotechnical ° <br /> 7 Out-Of-Service Well C Out-Of-Service Well Renewal 0 Cross-Connection Repair <br /> D New Pum �]Pump Replacement D Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method X Mud Rotary 7 Air Rotary C Auger 0 Cable Tool ❑Push Point 7 Other <br /> Proposed Well Depth 200 ft Excavation 14 In diameter D Open Bottom X Gravel Pack/Gravel Size No.6 in diameter <br /> I Conductor Casing in diameter / Conductor Casing Depth it Sand pack <br /> Well Casing Diameter 8 In Thickness/Gauge/ASTM Sched SDR26 D Steel XPlastic ❑Stainless Steel D Other <br /> Grout Seal Depth 100 ft ❑Neat Cement(94 lb bag/5-10 gal water) ❑Sand Cement sack mix17 gal water <br /> XBentonite(20%solids) D Other <br /> Grout Placement Method X Pumped U Free Fall U Other J Retardant/Accelerator(name) <br /> PEDESTAL Installed By 0 Driller Oy Pump Contractor ❑ Other <br /> 7 Concrete Pedestal Dimensions:Width it Length ft Thick In ❑Christy Box 0 Stove Pipe <br /> PUMP 7 Submersible❑Turbine ❑Other HP Pump Set it 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 /> MI MUM 24 HOUR ADVANCE NO bg _.- <br /> j 1_ED FO INSPECTIONS q <br /> SIGNED 1 4113 TITL DATE Z —;Z 17 <br /> In <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Area Employee ID# <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received Check#/ Amount Date Permit/ invoice# Well ID# <br /> Codes Info By Cash Remitted Service Re uest# <br /> 4 <br /> EHD 43-09 WELL RUMP PERMIT <br /> 8/04109 <br />