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.per . <br /> G WELL' /PUMP PERMIT <br /> j ANy 1N t.oVNTY EnYIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 31O FL-STOCKTON CA-95M <br /> I <br /> • T <br /> ( NON-REFUNDABLE P£RMIT -. CALL 209 953-7697 FOR INSPECTIONS EXPIRES'I (209)46"2020 <br /> REAR PROM DATE ISSUED <br /> .. <br /> tbe <br /> ion ADDRESS 18555 fMaCARTHUR RUM. ' - cm/zIP TRACY_tA 95304 <br /> S <br /> RO <br /> CSSTREET — d <br /> 4 � � APNE 13—OZO— 73 / PARCEL SIZE �•a,. LAND USE APPLICATION <br /> i QWNERNAME EDWARD FAGUNDES <br /> -` - -PHONE <br /> 'OWNER ADDRESS 18555 MAC ARTHUR BLVD. C.gmrATE/ZIP TRACY CA'95304 <br /> coNTpAcrost HENNINGS BROS.-DRILLING CO." INC. PHONE 545-1985- <br /> C <br /> RRACI'ORADDRPSB 3525 PEL'ANDAL'E AVE. <br /> CtrwSTATVZIP MODESTO,CA 95356 <br /> SUBCONTRACTOR - - <br /> PHONE <br /> SUBCONTRACTOR ADDRESS CrTY157ATElZlP <br /> I yI <br /> L CENSE b`1(C-57 0 C•61 ❑•13-09' O Other 'NUMBER•_ 90$1$ Ex"PATION DATE <br /> —31 <br /> GEOGRAPHICALINPORMATION: Coordinates % - - Y Township Rangy Section <br /> a <br /> IN7ENn D I1sE nomestic/Private D IrrigatiWAgricultuml 13 Industrial 0 Water Quality Monitoring G Sun Sampling/Chsrecterimaon <br /> U Public Wter$stem <br /> udirttrsut from er. - t.TYPE <br /> ������� e urs r <br /> aur rium oris anee ar <br /> TYPE.OE WOR X]New Well • O Replacement Well O Well Alteration/Modificstion O Other <br /> ,O Monitoring We11(s) #of wells d Soil Borin N dt hodrE Nor <br /> gO . .• O Geotechnical <br /> O Out-Of-Service Well O Out-Of-Service Well Renewal O Cross Cpnnection Repair <br /> R O New Pump, , 0 Pum R lacement O Pum R air _ <br /> WELL QgNsTgucrjoly <br /> DHlling Method Xl Mud Rotary O Air Rotary O Auger ''r` Cl Cable Tool d Push Point O Otho t� <br /> Proposed Well Depth_�ft Excavation 1211 i <br /> in diameter O Open Bottom )b Gravel Fack 1 Gravel Siu in diameter (!� <br /> O Conduetor'Caaing 4 � in diameter / Conductor Casing Depth it <br /> .Well Cadae Diameter 6 in Thickncss/Gauge/ASTM.Sched 160CL O Steel IN Plastic Q Stainless Stec] O Other V] <br /> Grout Seal Depth 100 _It 13 Neat Cement(94 1b bag/5.10 girl uVier) water <br /> wat <br /> gal Ir'O Sand Cement sack tars l 7 h <br /> ]til Bentonite(20%solids) ' O Manulketurer Spec Ori solids a/. Name El Specs oD File O Specs 7 gal wat <br /> Grout Placement Method Pumped O Fra Fall O Other - tted <br /> O Retardant 1 Accelerator(name) <br /> PEDESTAL Installed By O Drilla 11pumpContmetor q Other ' <br /> p O Concrete Pedettal Dimensions:Width ft I.ength' ft.Thick in O Christy Boi Oope <br /> P_k�_Ip O Submcrsibk O Turbinc O Other �: �_HP' .Pump Set -- <br /> P - - fl Standing Water LcvcI ft' <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN y <br /> RDINANCE STATE LA AND RULES AND REGULATIONS, 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> ( CURRENT AND ACTIVE WITH THECAL E'E9h1�AND�'{ WINS—WT4IALL <br /> 1] WORKERS COMPENSATION LAWS. <br /> l MINIMUM 24 HOUR ADVANCE OTICE REQUIRED FOR INSPECTIONS J, <br /> stcNED Ste_ T Le SUPERVISOR' xwm 5-30-07 <br /> ------------ <br /> f M <br /> f r <br /> ! . <br /> t r <br /> 1 <br /> E <br /> �a <br /> I — <br /> ;F_411- <br /> Mt M <br /> 110 iA <br /> AL <br /> R <br /> i <br /> L <br /> e <br /> H TM 3F <br /> I r ., -- <br /> DEPARTM£NTU�E. ONLY• <br /> _ .>,.Application Accepted By <br /> Grout[ w .5 Area- ——�— y Employee IDN <br /> nspection 8y IAi Dau.. O SPECWell Permit .. .-rp <br /> Pump Inspection By Date <br /> .13 'WAI VER Received - <br /> Constructed Well Depth R <br /> t COMMENTS AZF-j -dT—,DF "C.0A11 <br /> PE SC Recdred Check#/ Amount ' - 'Permit/ —7— <br /> Codes Info Bs Remitted Date Service R Uest9 Invoice# - Well ID# <br /> eras ao 1 .sa� t z67 <br /> i <br /> R nooi'.°°e <br /> - _ .. WELLPUWPEAMIT <br />