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WELL / PUMP PERMIT CANNA <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH D%aaWkTMENT 304 E WEBER rr,(3°e FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> 1.�. <br /> JOB ADDRESS 12833 S. MANTHEY RD. CITY/ZIP <br /> CROSS STREET K L 0 P D. APN L`7, j 230 0 7 PARCEL SIZE LAND-0SE APPLICATION# - / <br /> OWNER NAME DESTOP <br /> PRPIPELINE PHONE983-5'500 <br /> l <br /> OWNER ADDRESS 12833 S. MAPITHEY RD. clTv/sTATE/ZIP LATHROP 95330 <br /> CONTRACTOR HENNINGS BROS. DRILLING CO. , INC . PHONE 545-1185 <br /> CONTRACTOR ADDRESS 3525 P E L A 14 D A L E AVE. CRY/STATE/ZIP M O DE S T O ,C A 95356 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE X CO C-57 ❑C-61 ❑D-09 ❑Other NUMBER 290813 1 EXPIRATION DATE 5-31 -D3— <br /> GEOGRAPHICAL <br /> -31 -0 8GEOGRAPHICAL INFORMATION: Coordinates X Y Township _ Range_ Section_ <br /> INTENDED USE / Domestic/Private ❑IGigation/Agriculmrsl ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> ^'\ <br /> If different from ystem wala 5yetem C..wt N.orPho.e N.mW1 v <br /> TYPE OF WORK IgNew Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> ❑Monitoring Well(s) #Of wells ❑Soil Boring(s) #ofbomp ❑Geotechnical a orboringe <br /> ❑Out-Of--Service Well ❑Out-Of--Service Well Renewal ❑Cross-Connection Repair v _ <br /> ❑New Pump ❑Pump Replacement ❑Pump Repair (v- <br /> WELL CONSTRUCTION y..y� <br /> Drilling Method XdMud Rotary )byAir Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth 2 5 0 It Excavation 1 4,11 in diameter ❑Open Bottom Gravel Pack/Gravel Si=-in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter 8 in Thickness/Gauge/ASTM Sched S D R 17 ❑Steel Mastic ❑Stainless Steel ❑.Other <br /> Grout Seat Depth 200 ft ❑Neat Cement(94 Ib bag 15-10 gal water) )Sand Cement 10 . 3 sack mix/7 gal water <br /> ❑Bentonite(201/6 solids) ❑Manufacturer Spec%solids_% Name ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method EXPumped ❑Fra Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By O Driller X3 Pump Contractor ❑ Other <br /> ❑Concrete Pedestal Dimensions:Width it Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set It Standing Water Level ft <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH S <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH AL <br /> WORKERS COMPENSATION LAWS. <br /> Ml1 VM 24 H VJeNC EQUIR FOR_INSPECTIONS <br /> SIGNED 1.r" ITL SUPERVISOR DATE 7-31 -06 <br /> lit / <br /> fl <br /> G <br /> E n 4 <br /> IA- <br /> 71 <br /> P <br /> D RTMENTO,Mnl�� <br /> LY <br /> Application Accepted B _ Dete Area_ Employee ID#T l T P <br /> Grout inspectio By ❑ SPECIAL Well Permit <br /> ❑ WAIVER Received <br /> Pump Inspection <br /> Constructed well Depth ft <br /> COMMENTS • O <br /> PE SC Received h Amount Dam Permit/ Invoice# Well ID# <br /> Codes Info B Cash - Remitted Service R nest# <br /> WELL PUMP PERMIT <br /> EHD 43-02-006 <br /> 1127/20)5 <br />