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rDELL / PUMP PERMIT <br /> NAN JOAQUIN COUNTY ENVIRONMENTAL HEAL rII DEP4,. JtiENT 304 E WESER Av. FL-STOCKTON CA 95102 - (209)468-3410 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Jon ADDRESS16101 S . MURPHY RD . CITY/ZIP ESCALON , CA 95320 <br /> - q I0- q � PARCEL SIZE STREET N . 0FL0UISE Apr-4 203 � e <br /> �1'7 LAND USE APPLICATION# � <br /> CA <br /> OwNr:RNANIF JOHN LAGIER PHONE 993-0672 <br /> OWNER ADDRESS 16101 S . MURPHY RD . CITY/STATEIZIP ESCAL0N , CA 95320 <br /> CONTRACTOR HENNINGS BROS. DRILLING CO. , IPC . PHONE 545-1185 <br /> 1 MODEST <br /> 95356 r i <br /> CONTRACTOR ADDRESS 3525 P E L A N D A L E AVE . CITYISTATF/ZIP M O D E S F O CA 9 5 3 5 6 <br /> SUBCONTRAC I-OR PHONE <br /> SUBCONTRACTOR ADIIRr:55 l CITY/STATE/ZIP <br /> LICENSE XdC-57 ❑C-61 ❑ D-09 ❑Other NUMBER 290813 EXPIRATION DATE 5-31 -06 <br /> i <br /> GEOCRAP1HcnI.INr•OttMnriON: Coordinates X Y Township Range Section <br /> IN'i'LNDE.D USE Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> 0 Public Water SYStem <br /> If different from inner: Water.ystem Name Contact Name or Plione NumW <br /> TYPr:OF WORK X7 New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other <br /> N of borings ❑Geotechnical of borings <br /> ❑Monitoring Wcll(s) n oi'wclls ❑Saul Boring(s). <br /> ❑Well Destruction ❑OuI-OF-Service Well ❑Out-Of-Service Well Renewal <br /> ❑Ncw 11unip Pum)Kc Iacenicnt ❑Punt 1 Repair ❑Crass-Connection Repair <br /> WELL CONSfRIIC'I'ION <br /> Drilling Method ,)17 Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool Cl Push Point 13 Other <br /> Proposed Well Depth 200 il Excavation 12 in diameter ❑Open Bottom X3 Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter I Conductor Casing Depth ft <br /> Well Casing Diameter 6 in ThicknesslGaugclASTM Sched 1 6 0 C L ❑Steel 10 Plastic ❑Stainless Steel ❑Other <br /> i Grout Seal Depth 10 0 1 ti ❑Neat Cement(94 Ih hub/5-10 gat water) ❑Sand Cement a'ack mix 17 gal water <br /> Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method XVPumped Cl Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL. Installed By ❑Driller 00 Pump Contractor ❑Other <br /> Cl Concrete Pedestal Dimensions: Width R Length It Thick in ❑Christy Box ❑Stove.Pipe <br /> PUMP ❑Submersible ❑Turbine ❑Other HP ":— ^--Pump-Sel ft Standing Water Level R <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT TH� WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS., I ALSO CERTIFY THAT MY REQUIRED LICENSE 1S <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. i <br /> MINIMUM 24 HOUR ADVAN NOT] E REQUIRED FOR INSPECTIONS <br /> SIGNED `�'� ire - S� U'Ft�4.E SUPERVISOR DATE 12-4-04 <br /> I t <br /> 4 rt <br /> - - <br /> l I, <br /> Y 10 <br /> ti <br /> 50- <br /> Vm .it r <br /> m 1•• S <br /> r_+ S <br /> I <br />'"s K tri <br /> t a Z 6 <br /> i <br /> r � <br /> r <br /> '-." 6�L P A RTM ENT 11 SE 'ON-L'Y <br /> ON-L'Y <br /> /L ( r <br /> Application Accepted By Date Area 2- ( j <br /> Employee 1D4 <br /> (trout Inspection By _ _ Date 0 ❑ SPECIAL Well Permit on r fI�,9 <br /> Pump Inspecti13 Date ❑ WAIVER Received �I` "l\ <br /> Destruction Inspcctiotn By Date Constructed Well Depth It <br /> COMMENTS •-e- <br /> - <br /> PE SC Received Check# Amount Permll/ <br /> Codes Info By Cash Remitted pate Service Request# Invoice# Well ID# <br /> Li 6 <br /> EIID 0-02-006 WELL PUMP PERMIT <br /> W6,04 <br />