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% /c, <br /> WELL/PUMP PERMIT d P ty, <br /> •• SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205-6232-(209)468-3420 jJj .j—// <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JoBADDRESS 6120 W Durham Ferry Rd CmZP Tracy 95304 I y <br /> CROSS STREET E of N Christmas Rd APN 253-250-26 PARCEL SIZE LAND USE APPLICATION# <br /> rn <br /> OWNER NAME Rose Ranch Inc._ c/o Jack Rose PHONE 831-0962 <br /> OWNER ADDRESS P.O. Box 83 CITYISTATE/LP Tracy,CA 95378 <br /> CONTRACTOR Hennings Bros.Drilling Co., Inc. PHONE 209-545-1185 <br /> CONTRACTOR ADDRESS 1930 Ladd Rd CITY/STATE/ZJP Modesto,CA 95356 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE x C-57 C-61 D-09 Other NUMBER 290813 ExPIRATIONDATE 05-31-2017 <br /> GEOGRAPHICAL INFORMATION: Coordinates Y Township_ Range Section_ <br /> INTENDED USE x Domestic/Private ❑Irrigation/Agricultural f. Industrial J Water Quality Monitoring 7 Soil Sampling/Characterization <br /> J Public Water System <br /> If different from Owner: Water System am e ntaCt Name or Phone NUM or <br /> TYPE OF WORK �9 Replacement Well Well Alteration/ModificationOther <br /> Monitoring Well(s) #of wells _Soil Boring(s) #of borings Geotechnical #of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> I New Pump I Pump Replacement -1 Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method x Mud Rotary %Air Rotary I Auger 0 Cable Tool ❑Push Point _� Other <br /> Proposed Well Depth��ft Excavation 14 in diameter ^I 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 Thi s/Gauge/ASTM Schad SDR26 LJ Steel IK Plastic -I Stainless Steel n Other <br /> Grout Seal Depth I Neat Cement(94/b bag/5-10 gal water) 0 Sand Cement sack mixr7 gal water <br /> x Bentonite(20° solids) 7 Other <br /> Grout Placement Method x Pumped I:Free Fall I Other J Retardant/Accelerator(name) <br /> PEDESTAL Installed By a Driller k Pump Contractor t Other <br /> I Concrete Pedestal Dimensions:Width ft Length ft Thick in 0 Christy Box 0 Stove Pipe <br /> PUMP J Submersiblei I 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. 1 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 HOUR ADVAIlN E NOT E R I `,D FOR INSPECTIONS r <br /> SIGNED O TITL l •f DATE It-Z3 <br /> r <br /> cEFNT <br /> AFD <br /> IV 2 3?416 <br /> N CO <br /> UI <br /> H""EA4 <br /> 7A <br /> L T <br /> DEPARTMENT U E O LY <br /> Applica ion Accepted By ate Area Employee ID#_� <br /> Grout Inspection ByDate SPECIAL Well Permit <br /> Pump Inspection By' Date WAIVER Received <br /> Soil Boring Ins action By ,Date Constructed Well Dept ft <br /> r <br /> COMMENTS U <br /> t -raw** L-" <br /> PE SC Received Check#/ Amount PermiU -� <br /> Date Invoice# WellID# <br /> Codes Info B Remitted Service Request# <br /> 1:4 0003Q,530 <br /> �jj - 40_T__T_ <br /> EHD 43-06 -5e't ,- / WELL/PUMP PERMIT <br /> 8/04/08 YYY <br />