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• WELL/PUMP PERMIT • <br /> ~ SAN JOAQNN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 WEBER AVE 3"FL-STOCKTON CA 95202 -(209)468-J/20 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> JOBADDRESS 25080 S. Banta Rd. �^L��-rnq r����.�.,/���� CRY/ZIP Tracy, Ca 95304 <br /> CROSSSTREET APN� Lµt'fPARCCL BILE /�/ LAND USE APPLICATION N g <br /> OWNER NAME Glenn Robart RooPHONE A76_0005 <br /> OWNERADDRESS 25080 S. Banta Rd- CITYISTATEIZIP Tracy C..A Q51nd <br /> CONTRACTOR Hennings Bros Drilling EG- Inc- PHONE Fd F_11RF <br /> CONTRAcTORADDRESS 3525 Relandale Ave. CITYISTATE/ZIP Mod s .o. CA 95356 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATFJDP \1 <br /> LICENSE Ek-57 ❑C-61 - ❑I}09 0Other NUMBER 290813 EXPIRATION DATE MAY 31.2006 1{I`^�nl <br /> GEOGRAPHICAL INFORMATION: CMMiD'Nl X Y TOwmMp_ Range_ Section_ .�.'�Ci1 <br /> INTENDeD USE DomatiMPrivatc O migatioNAgriculsural ❑]aduetliel ❑Water Quality Moniknng ❑Soil Sampling/Charackdation <br /> ❑P blit Water 3y¢tem <br /> IldiRaem from Ownee emr INn eme ndm rnw or ne um <br /> TYFEOF WORK ❑New We11 rb Replacement Well ❑Well Alteration/Modification ❑Test Hole 13 Other V• <br /> ❑Monitoring Well(s)_Worwelli ElSoil Boring(s) xofbvrin, ❑Geotmhnical xRfbvdap <br /> ❑Well Destruction O Out-Of--Service Well ❑OutOfServiec Well Renewal <br /> ❑New Pum ❑Pump Rapplaccamint ❑Pump Repair ❑Cries-Connection Repair <br /> WELL CONSIRUC ION <br /> Drilling Method 10 Mud Rom, ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth sorra E...vMion1DD i^ni•mnn ❑Coen Bottom tel Gravel Pick/Gravel Si.—m diameter 1 <br /> ❑Conductor Casing in dimsdei _R <br /> !WWeell Cis ng Diameter 6 in Thick..,/Gauge/ASTM ^. ❑3, <br /> [Grout Seel Depth 2001+ fl ❑N..CemrntO� / " ( save Svblwater <br /> F[ ❑Bentonite(20%solids) -,Manuflctukr (/,(, (' peva Submitted <br /> Grdyt Placement Method )b Pumped E3 Free Fall 00 <br /> PEDESTAL 1,0010 B, C)Dnllar IM P, <br /> ❑Concrete Pedestal Dlmemloni: Wid 4ave pip. <br /> POMP ❑Submersible ❑Turbine ❑G /A { � 7,-a,.� fl <br /> WELL DESTRUCTION ❑Opea Bottom rat <br /> Well Diameter Ain Total Depth f, I to It <br /> Saling Material ❑Neat Cement(941h bag 15-10 gal <br /> ❑Beetonite(20%solids) ❑ManufacNn Spres Submitted <br /> Placement Method bPumped ❑Free Fall N <(4'Nn/ <br /> O Complete with Mushroom Cap <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS NK-'t/V -'E WITH SAN <br /> JOAQUIN COUNTY ORDINANCES,STATE LAWS AN 0 LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA C( / :E WITH ALL <br /> WORKERS COEMPENSATION <br /> ZZd MNIMU1M 24 HOUR /`( l <br /> SIGNED t1\.(�:.'(S.Ig...'1 X11 ...,N�--�.)''.\1.LL'd 04 <br /> u <br /> AN <br /> 4 <br /> 49 <br /> DEPARTMENT USE LY �t���p <br /> Application Accepted By ( Date l L Area EmDloya IDp � <br /> Grout Inspection By A /J Y—' Date ❑ SPECIAL Well Permit J <br /> Pump lospectio _ to ❑ WAIVERRecelved <br /> Des mction Inspecti By Dak�,7 Constructed Well Depth ,7 H <br /> COMMENTS I 1 E+ ' r_ y - 6""e yJ "' F yLS� <br /> -� 205- ca,..`M1v �o'-f.5< e uNd .L !. <br /> Oe , 't/ Tva L'BsversJh ew ui Pae 0ts at. .sir r-/v <br /> PE SC Raelved Amount Date Pt IV Weill <br /> Cod Info B Cash R mitred Service Request# <br /> Y3131 /3/7 -2 0 59-0g)-bS 25 <br /> 225 h" T'7 P <br /> END 43-02na yams L_<cAQu/t<o,��i-2�t-f��+iraY'=l 7'��lr <-7 �coAErLTR:W H <br />