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` /0 ! 3`0 WELL / PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTEPARTMENT 304 E WEBER6E 3°°PL-STOCKTON CA 95202 -(709)068-3430 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 10800 E. HWY 120 CITY/ZIP MANTECA 9s336 y <br /> CROSS STREET 1 M I. E. OF HWY 99 AIN Za 2#.PARCEL SIZE f,3KLAND USE APPLICATION M <br /> OWNER NAME MANTECA RV STORAGE/TERRY DAVIS C/o DELTA PUMP PHONE 466-9625 rrrririri <br /> OWNER ADDRESS 646 S. CALIFORNIA ST. CIT'/STATE/ZIP STOCKTON,CA 95203 <br /> CONTRACTOR HENNINGS BROS. DRILLING CO. , INC. PHONE 545-1185 <br /> CONTRACTOR ADDRESS 3525 PELANDALE AVE. CITY/STATE/ZIP MODERSTO, CA 95356 <br /> SUBCONTRACTOR PHONE Q <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE 101 C-57 ❑C-61 ❑D-09 ❑Other NUMBER 29DB1 EXPIRATION DATE 5_31_OR <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township _ Range_ Section_ <br /> INTENDED USE ❑Domestic/Private UIrrigatioNAgricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System FIRE PROTECTION <br /> Ifdifferm,from Owner:, Water System Nam Contact Name or Phone Number <br /> TYPE OF WORK lb New Well ❑Replacement Well ❑Weil Alteration/Modification ❑Other <br /> ❑Monitoring Well(s) Hofwells E3 Soil Boring(s) sofbodngs ❑Geotechnical Nofboi.ga <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ❑New Pump ❑Pump Replacement ❑Pump Repair G <br /> WELL CONSTRUCTION <br /> Drilling Method KI Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth 250 it Excavation 1811 in diameter ❑Open Bottom �`)Gravel Pack/Gravel Sin in diameter <br /> ❑Conductor m m diameter / Conductor Casing Depth ft <br /> Well Casing Diameter m Thi kness/Gauge/ASTM Schad SDR26 ❑Steel [X Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth 50 ft ❑Neat Cement(9416 bag/5-10 gol water) ❑Sand Cement sack mix/7 gal water <br /> V <br /> Bent m (20%sol' ) ❑Manufacturer Spec <br /> solids % Name ❑Specs on File 11 Specs Submitted <br /> Grout Placement Metho Pu ed ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller IX Pump Contractor ❑ Other <br /> ❑Concrete Pedestal Dimensions:Width ft Length it Thick in ❑Christy Box ❑Stove Pipe <br /> uMP ❑Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level ft <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUI OUNTY 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 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> � w <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED QY1�. 1-1 Ste' TITLE SUPERVISOR DATE 5-3-07 <br /> P/,YM Er JT <br /> IE kLT i qEF�RJM T 11 <br /> S <br /> �^ �) D�ARIi' MENT SE� ON LY ���/ <br />