Laserfiche WebLink
1-r�ft � SCx� 1-1-IT OSin <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 /> ly <br /> JOB ADDRESS 3203 W Kenner Rd CITY/ZIP Tracy,95304 ig <br /> D <br /> v <br /> CROSS STREET N of Dreyer Rd APN 255-060-4$�1 PARCEL SIZEZLVL-3 AND USE APPLICATION# °z <br /> m <br /> OWNER NAME M&R-and-Lois Brenkwitz. t ► r PHONE 209-483-5065 <br /> OWNER ADDRESS 3 Kenner 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 C-61 1,D-09 i Other NUMBER 290813 EXPIRATION DATE 05-31-2018 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br /> INTENDED USE X Domestic/Private I Irrigation/Agricultural C Industrial I Water Quality Monitoring ,Soil Sampling/Characterization <br /> 1 Public Water System <br /> If different from Owner Water bystem Name Contact Name or Phone um r <br /> TYPE OF WORK X New Well -I.Replacement Well Well Alteration/Modification J Other <br /> Monitoring Well(s) #of wells I Soil Boring(s) #of borings C Geotechnical #of borings <br /> Out-Of-Service Well I- Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump J Pump Replacement I I Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method X Mud Rotary 7 Air Rotary Auger I I Cable Tool n Push Paint � Other <br /> Proposed Well Depth 250 it Excavation 14 in diameter I Open Bottom X Gravel Pack/Gravel Size No R in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft Sand pack <br /> Well Casing Diameter 8 in Thickness/Gauge/ASTM Sched SDR26 I Steel X Plastic 'i Stainless Steel l Other <br /> Grout Seal Depth 100 ft -Neat Cement(94/b bag/5-10 gal water) ❑Sand Cement sack mixR gal water <br /> XBentonite(20%solids) -Other <br /> Grout Placement Method X Pumped Free Fall I I Other i Retardant/Accelerator(name) <br /> PEDESTAL Installed By it Driller X Pump Contractor n Other <br /> I Concrete Pedestal Dimensions:Width ft Length ft Thick in n Christy Box ❑Stove Pipe <br /> PUMP -Submersible I Turbine '- Other HP Pump Set ft Standing Water Level It <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 /> MIN MUM 24 HOUR ADVANCE N E REQUIRED FOR INSPECTIONS �J <br /> SIGNED TITLE Y• DATE <br /> Q - W <br /> Z N OE"' <br /> W W <br /> � W o � <br /> 0 <br /> a LW <br /> 7M 1A 3es <br /> nj <br /> D 1 RTMENT U E ONLY ������//•//��cc//���� �",�/�__ <br /> Application Accepted ate Area Employee ID#���//// TL�� <br /> Grout Inspection By Date 111 PECIAL Well Permit -'/ <br /> Pump Inspection By Date WAIVER Received c rJ✓" <br /> Soil Boring Inspection By Date Constructe a pth ft <br /> COMM <br /> PE SC Received Chec #/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By <br /> �7Cas�hy�/ Remitted Service Request# <br /> 5 W PCU 1,d <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 8/04/08 <br />