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WELL / PUMP PERMIT 00 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH D6'AARTMENT 304E WESEh,.WE 3a"FL-ST 8-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> w <br /> a <br /> JOB ADDRESS 5590 1I . GRANT LI"IE R0 . CITY/ZIP TRACY y <br /> CROSS STREET SIXTH S T. APN 250-050-06 PARCEL SIZE �' LAND USE APPLICATION# <br /> ne <br /> OWNERNAME TINA DUNCA14 PHONE 510-712-6963 <br /> - OWNER ADDRESS P . O. BOX 766 CITY/STATwzU, TRACY., CA 95304 <br /> CONTRACTOR HENNINGS BROS . DRILLING CO. ,'I.NC. to_ PHONE 545-1165 <br /> CONTRACTOR ADDRESS 3525 P E!A N O A L E AVE. A CITY/STATE/ZIP H O D E S T O ,C A 95356 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE XIS C-57 ❑C-6I ❑D-09 ❑Other NUMBER_Z213 13 EXPIRATION DATE 5-31 -08 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township _ Range Section_ <br /> INTENDED USE 11 Domestic/Private ❑Irrigetion/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> [(different from Owner: Wm,System Nam Comet Nam or Phone Number <br /> TYPE OF WORK X'3 New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> ❑Monitoring Well(s) #of wells ❑Soil Boring(s) n of bonngs ❑Geotechnical sof borings <br /> ❑Out-0F-Service Well ❑Out-0f-Service Well Renewal ❑Cross-Connection Repair (JI <br /> ❑New Pump ❑Pump Replacement - ❑Pump Repair <br /> WELL CONSTRUCTION <br /> Drilling Method )b Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth 530 ft Excavation 12 in diameter ❑Open Bottom X7 Gravel Pack/Gravel Size in diameter V <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter 5 in Thickness/GaugrJASTM Sched SDR 1 7 ❑Steel b Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth 2001 ft ❑Neat Cement(94 lb bag 15-10 gal water) ❑Sand Cement sack mix/7 gal water <br /> X)Bentonite(20%solids) ❑Manufacturer Spec%solids_% Name ❑Specs on File ❑Specs Submitted <br /> Grout Platement Method X7 Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) \^f <br /> FPEDESTAL Installed By ❑Driller Pump Contractor ❑ Other l <br /> l:}t nBeTe cdestsd Di ensions:Width ft Length it Thick in ❑Christy Box ❑Stove Pipe <br /> ImME ❑Submersible ❑Turbine ❑Other HP Pump Set --ft-Standing--Water Le L+-- - <br /> 1 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 /> COMPENSATION LAWS. <br /> WORKERS COMP - <br /> MINIMUM 24 HOUR DVANCE N TICE REQUIRED FOR INSPECT ONS <br /> SIGNED `( $e1`� rL SUPERVISOR DATE 5024-OI.O <br /> W 41 AF <br /> 2[3b a <br /> so m L..ia Iga <br /> • (r <br /> y lu <br /> 1Ttl fill I IRI 141 <br /> Sl a i <br /> � r <br /> O S = <br /> E P o <br /> s <br /> D - ARTME-NT U-SE ONLX_ <br /> Application Accepted By to Area Employee ID# / <br /> Grout Inspectio y Dater - ❑ SPECIAL Well Permit <br /> Pump Inspection y m '���"�-4� Date ❑ WAIVER Received <br /> Constructed Well De th 4 It <br /> COMMENTS — CO/IRrg a (r t5 o+lc f L of- I( <br /> PE SC Received Check#/ Amount Permit/ <br /> Coda Info B as Remitted Date Service Request# Invoice# Well IDM <br /> 7 ' Zu�Da a2 <br /> END 43-03-006 WELL PUMI'PSaMiT <br /> IR7R005 <br />