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T"4'tA S(-"%-\ �-ie;i u qj4/b 230 <br /> WELL/PUMP PERMIT <br /> 4 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 27927 Vine Ave cITY2'P Escalon 95320 <br /> ID <br /> �y Qj� 0 <br /> CROSS STREET East of Harrold Ave APN 249-030-08 PARCEL SIZELAND USE APPLICATION# m <br /> OWNER NAME Gerald&Roberta 4AeSfR-.bLr ih PHONE 481-6349 •`/' <br /> OWNER ADDRESS 27927 Vine Ave CITY/STATEIZIP Escalon.CA 95320 <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 k C-57 C-61 i D-09 I Other NUMBER 290813 EXPIRATION DATE 05-31-2017 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section <br /> INTENDED USE X Domestic/Private i_I Irrigation/Agricultural Industrial Water Quality Monitoring 7 Soil Sampling/Characterization <br /> Public Water System <br /> II different from Owner: water uystern Name Contact Name or Phone NUm4er <br /> TYPE OF WORK ,A M€w Well replacement Well " Well Alteration/Modification ;Other <br /> Monitoring Well(s) #of wells r_ Soil Boring(s) #of borings F Geotechnical #of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> New Pump Pump Replacement I_ Pump Repair I Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method X Mud Rotary I Air Rotary I Auger F!Cable Tool L Push Point i Other <br /> Proposed Well Depth 250 ft Excavation 14 in diameter ❑Open Bottom X Gravel Pack/Gravel Size 6/8 Blend in diameter <br /> I Conductor Casing in diameter / Conductor Casing Depth It <br /> Well Casing Diameter 8 in Thickness/Gauge/ASTM Sched SDR26 ❑Steel k Plastic ❑Stainless Steel I I Other <br /> Grout Seal Depth 100 ft I I Neat Cement(94/b bag/5-10 gal water) ❑Sand Cement sack mix/7 gal water <br /> X Bentonite(20%solids) I Other <br /> Grout Placement Method X Pumped I I Free Fall I I Other -i Retardant/Accelerator(name) <br /> PEDESTAL Installed By U Driller X Pump Contractor n Other <br /> I Concrete Pedestal Dimensions:Width ft Length ft Thick in .J Christy Box 1..Stove Pipe <br /> PUMP Submersibles. Turbine r 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 /> MINIMUM 24 HOUR AD ANCE OTIC RE ED FOR <br /> /y <br /> R INSPECTIONS Q n <br /> SIGNED 'TLE `Y \ DATE <br /> Amiga <br /> 1 <br /> IF <br /> ILD <br /> PAYlip <br /> REC <br /> AUG <br /> JOA <br /> SAN <br /> tie.- L'ADEPARTMENT USE (fONLY —�l!l!�j.. <br /> Application Accepted By Uzie, ( l Area : 6 Employee ID <br /> Grout Inspection B - I / Date !9 —Z SPECIAL W@II Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Insp ction By Date Constructed Well Depth ft <br /> COMMENTS u-IA '" � w Y i ti- - <br /> aw i K !o yam 10 <br /> SPE SC Received hec Amount Permit/ <br /> Codes Info B ash Remitted Date Service Re uest# Invoice# Well ID# <br /> 36105-7 -U,t"' T�- S o0 7Szf 7 p0 q l2 <br /> 3 91, 7 7. 115'.o Q 9 s- I( lI <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 8/04/08 <br />