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7�� - WELL/PUMP PERMIT ®~ <br /> �SAN JOAQUINCOUNTY ENVIRONMENTALHEALTHDEPARTMENT <br /> 304BWEBER AVE 3"'FL-STOCKTONCA ' 2 - (209)468.3420 <br /> NON-REFUNDABLE PERMIT CALL(,. 953-7697 roR INSPECT1oN'S EXPIRES 1'YEAR FRC -SATE ISSUED i <br /> JOB ADDRESS 3737 11. 11th ST. CITYIZIP tracy 95304 a <br /> CROSSSTREET S.W. corner of 11th & Grantlin,,&N 239-070-03 PARCELSIZE O.31 eec <br /> OWNERNAME LARRY ALEGRE PRONE 652-2855 <br /> OWNERADDRESS 3703 �1. GRA T�-I THE PD. CITY/STATEIZIP TRAfY, rA 953n4 ' <br /> j CONTRACTOR 1-FNNINGS AR,0S, nplll ING Co INC- -__ — PHoNg 652-2855 <br /> k CONTRACTOR ADDRESS 3525 PELANDALE AVE. CITY/STATEIZIP MODESTO, CA 95356 <br /> a ` <br /> SUBCONTRACTOR PHONE J <br /> SUBCONTRACCORADDRESS CITY/STATEIZIP - <br /> -� LICENSE t C-57 Q'C-61 ❑D-09 ❑Other NUMBER 2 0 'l EXPIRATION DATE 9-3_j--() <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range S.Ii.r. <br /> INTENDED USE IX Domestic/Pnvate ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring O Soilumampling/Characterization <br /> 13 Public Water System <br /> Vdiff—t from O net. Water ystem am nntan ame or <br /> TYPE OF WORK diNew Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other <br /> ❑Monitoring Well(s) )�') <br /> numherof—IIs ❑Soil Borings) numberof6 ❑Geotechnical oings —b,orborinbn <br /> F <br /> ❑Well Destruction 0 Out-Of--Service Well Q Out-Of-Service Well Renewal <br /> ❑New PLmp ❑Pump Replacement D Pump Repair O Cross-Connection Repair <br /> WELL CONSTRUCTION <br /> Drilling Method IXMud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point 11Other <br /> Proposed Well Depth 170 R Excavation 12 in diameter ❑Open Buuom 01 Gravel Pack/Gravel Size in diameter <br /> r _ 0 Conductor Casing in diameter / Conductor Casing Depth it <br /> i Well Casing Diameter 6 in ThicknesslGaugeJASTM Sebed SDR_{] ❑Steel IXPlastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth 'l O O R 0 Neat Cement(94 1b hag/5-11)got water) C,XSand Cement 10.1 sack mix 17 gal water <br /> Cl Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method IX Pumped ❑Free Fall ❑Other ❑Retardant I Accelerator(name) <br /> PEDESTAL Installed BY ❑Driller )'t(Pump Contractor ❑Other - <br /> Fi <br /> L3Concrete Pedestal Dimensions: Width_ft Length R Thick in ❑Christy Box ❑'Stove Pipe <br /> PUMP ❑Submersible 13Turbine ❑Other HP Pump Set ft Standing Water Level- ft <br /> WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other - <br /> Well Diameter in Total Depth ft Depth to Water ft ❑Casing to be Perforated from ft to ft <br /> rr Seating Material 0 Neat Cement(941b hag/3-10 gal water) ❑Sand Cement sack mix 17 gal water ❑Bentonite Pellets <br /> 0 Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Spcos on File ❑Specs Submitted I� <br /> Placement Method ❑Pumped 0 Free Fall Q Other -x <br /> ❑Complete with Mushroom Cap ft below grade ❑Complete to Existing Surface Pad <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL.BE DONE IN ACCORDANCE WITH SANS( <br /> JOAQUIN COUNTY ORDINANCES,STATE LAWS, AND,RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSEIS I ' <br /> r 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 ADVANCE NOTICE REQUJItED FOR INSPECTIONS—PLEASE CALL(209)953-7697 <br /> SIGNED :Q ' Co S F 1 5 - R' n <br /> r <br /> ir <br /> .r~ <br /> h <br /> • e <br /> i - S EN IR N C U TSF <br /> I <br /> eI <br /> IF <br /> 1 Application Accepted By - Date <br /> Area --mm Employce IDN <br /> Grout Inspection By bate ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> 1 Destruction Inspection By Date Con tr cted W 1 De th ft <br /> COM ENTS t" C . o ✓ <br /> PE Sc Received Chec Amoun Permit/ <br /> Codes Info B ash Remitted 1� Date Service Re uest# IDvoiCe# Well ID4 <br /> { <br /> EHD 43-02-006 <br /> t,,at, Q� � MASTER WATER WELL PERMIT <br /> 32/672002 <br />