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r ' WELL/PUMP PERMIT <br /> < < SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205-6232-(209)468-3420 <br /> NON-REFUNDABLE PE MIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> LA <br /> JOB ADDRESSiA <br /> 6867 Cox Rd CITymp Linden,95236 <br /> D <br /> 0 <br /> CROSS STREET S of Comstock Rd APN 091-240-43 PARCEL SIZE •V LAND USE APPLICATION# <br /> in <br /> m <br /> OWNER NAME Lynette Hart PHONE 209-887-3187 <br /> OWNER ADDRESS P.O..Box 450 CITY/STATE/ZIP Linden,CA 95236 <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 1 C-61 D-09 Other NUMBER ExPIRATTON DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br /> INTENDED USE X DomesticlPrivate Irrigation/Agricuftural 11 Industrial I Water Quality Monitoring L:Soil Sampling/Characterization <br /> I <br /> i Public Water System <br /> If different from Owner: a er UySteM Nam on a ame or one um r <br /> TYPE OF WORK iX New Well i Replacement Well i Well Alteration/Modification r;Other <br /> ri Monitoring Well(s) #of wells i i Soil Boring(s) #of borings Geotechnical fl of borings <br /> L1 Out-Of-Service Well i Out-Of-Service Well Renewal i Cross-Connection Repair <br /> i New Pump i i Pump Replacement i 1 Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method X Mud Rotary i_i Air Rotary j Auger i_; Cable Tool i.Push Point 1 l Other <br /> Proposed Well Depth 350 ft Excavation 14 in diameter 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 tThh ess1Gauge/ASTM Sched SDR26 !Steel X Plastic r Stainless Steel Other <br /> Grout Seal Depth-i fig 19 Neat Cement(94 Ib bag/5-10 gal water) i Sand Cement sack mixf7 gal water <br /> X Bentonite(20%solid ) Other <br /> Grout Placement Method x Pumped _:Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller X Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width It Length ft Thick in Christy Box Stove Pipe <br /> PUMP Submersible[ Turbine I 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 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 24 HOUR AQV/jN E CE REQUIRED FOR INSPECTIONS <br /> SIGNED , e* — TITLE Y 4 r • DAIr <br /> TE r 1 <br /> del <br /> IV <br /> � R cFVHr <br /> NY Eo <br /> /y '10 MY <br /> EP RTMENT SE ON Y <br /> Application Accepted By Date Area � Employee ID#��ai�L�' - <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection Dale WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received heck#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info Remitted Service Request# <br /> /--2-- /7 6b 00031131140 <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 8/04106 <br />