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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 />NUN-KEFUNDABLE PERMIT tLALL (LUV) V0J-1bV/ FOR INSPECTIONS r-A'IKtb l YEAR FROM DATE ISSUED <br />JOB ADDRESS 16590 S. Murphy Rd. crry/zIP Escalon 95320 <br />CROSS STREET S- Of Louise Ave-APN 203-220-01 PARCEL SIZE 40 LAND USE APPLICATION # <br />OWNER NAME Hendley Farming, Inc. PHONE 209-985-4955 <br />OWNER ADDRESS 16590 S. Murphy Rd. CITY/STATE/ZIP Escalon. CA 95320 <br />CONTRACTOR Hennings Bros. Drillinq Co., Inc. PHONE 209-545-1185 <br />CONTRACTOR ADDRESS 1930 Ladd Rd. CITY/STATE/Zip Modesto, CA 95356 <br />IR ADDRESS CITYISTATE/ZAP, <br />C-57 7 C-61 a D-09 I Other NUMBER 290813 <br />PHONE <br />EXPIRATION DATE 5-31-18 <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township _ Range Section_ <br />WENDED USE Domestic/Private Xlrrigation/Agricukural I i Industrial 7 Water Quality Monitoring �. i Soil Sampling/Characterization <br />Public Water System <br />If different from Owner Water Uystern Name Gontadt Nam or one Number <br />TYPE OF WORK XNew Well Replacement Well 1 Well Alteration/Modification 1-i Other <br />Monitoring Well(s) # of wells i I Soil Boring(s) # of borings I Geotechnical # of borings <br />Out -Of -Service Well Out -Of -Service Well Renewal 1 Cross -Connection Repair <br />rcalSe <br />Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point X Other Reverse Rotary <br />Proposed Well Depth 400 ft Excavation 22 in diameter i Open Bottom XGravel Pack/Gravel Size #6 in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter� 2 in Thickness/Gauge/ASTM Sched SDR21 ❑ Steel XPlastic I Stainless Steel Other <br />Grout Seal Depth 50 ft I Neat Cement (94 Ib bag/5-70 gal water) i Sand Cement sack mixl7 gal water <br />XBentonite (20% solids) I I Other <br />Grout Placement Method XPumped l Free Fall Other Ti Retardant / Accelerator (name) <br />PEDESTAL Installed By i Driller rump Contractor i Other <br />Concrete Pedestal Dimensions: Width it Length it Thick in ; i Christy Box i Stove Pipe <br />PUMP - Submersible i Turbine 1 Other HP Pump Set It Standing Water Level it <br />I HEREBY CERTIFY THAT 1 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 />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 />rA <br />D <br />0 <br />M <br />m <br />w <br />PE SC Received Check#/ Amount <br />Codes Info By Cash Remitted <br />Date Permit/ Invoice # Well ID# <br />Service Re uest # <br />EHD 43-08 WELLIPUMP PERMIT <br />8/04/08 <br />