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ELL 1 PUMP PERMIT <br /> AN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 3114 E WEBER A tm FL-STOCRTpN CA 95202 - (209)468-342 <br /> ANON-REFUNDABLE PERMIT CALL(204)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> GG m <br /> FJoB ADDRESS 5 5 3 /Jrr� (n) [P)VITYIZIP S T O .K TO C A 9 S Z�� c <br /> OSs STREET SOUTH O F E I H P �lt7 U�7 Q— � _ PARCEL Si7.E 3 3 <br /> OWNER NAME ROBERT JONE5 PIIONE <br /> OWNER ADDRESS 5533 0 U A S H N I C K RD , _ CITYISTATEIZIP S T O C K T f)N , CA 9 5 212 <br /> i <br /> Ll <br /> CONTRACTOR HENNINGS BROS . DRILLING CO. , INC . . PRONE 545-1185 <br /> 3525 PELANDALE AVE . CITYISTATEIZIP N�ODEST0 , CA 95356-9781 Cti1 <br /> CONTRACTOR Annl:css W <br /> SUBCON'T'RACTOR PIIONF, <br /> In <br /> I <br /> SUBCONTRACTOR ADDRESS - CITYISTATEIZIP <br /> a <br /> LICENSE. IMC-57 ©C-61 ❑D-09 ❑Other NUMBER�9 0 8.1.3 EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization S <br /> ❑Public Water System ';r <br /> If different from Owner: Water System Name Contact Name or Pfione Number <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other 3 <br /> number of welts number of borings number of borings <br /> C]Monitoring Well(s) ❑Soli Bvring(s} ❑Geotechnical <br /> Mell Destruction ❑Out-Of-Service Well ❑Out-Of-Scrvice Well Renewal <br /> { ❑New Pump ❑Pump Replacement ❑Pump Repair ❑Cross-Connection Repair <br /> WELL CONSTRUCTION <br /> { Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other �1 <br /> Proposed Well Depth ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth It <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Stec] ❑Plastic 13Stainless Steel L3Other <br /> r <br /> Grout Seal Depth ft Q Neat Cement(94 lb hug I5-IOgul water) El Sand Cement suck mix 17 gal water t/I] <br /> t ❑Bentonite(220%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant i Accelerator(name) C� <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑Other r'y <br /> + ❑Concrete Pedestal Dimensions: Width ft Length ft Thick in Q Christy Box ❑Stove Pipe 3 <br /> PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level ft <br /> WELL DESTRUCTION ❑Open Bottom IN Gravel Pack ❑Uncased ❑Other <br /> Well Diameter bin Total Depth 1 nkn= _ft Depth to Water It ft ❑Casing to be Perforated from ft to 11 I <br /> Scaling Material ❑Neat Cement(941h hub/S-10 gal water) YdS.nd Cement 10 . 3 sack mix 17 gal water ❑Bentonite Pellets <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Placement Method X1 Pumped ❑Free Fall ❑Other <br /> ,Mompletc with Mushroom Cap L ft below grade Q Complete to Existing Surface Pad <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN 1 <br /> r <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS k <br /> CURRENT'AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL € <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQU IkFJI,EOR INSPECTIONS— PLEASE CALL(209)953-7697 ` <br /> I SIGNED 1� 5PERVISOR DATEi]�2 9-2003 <br /> r <br /> ; — F <br /> a <br /> O IN I. <br /> I r w ✓ �, S 'sr..L1 St i�l 4510N <br /> l. . <br /> DEPARTMENT USE ONLIq <br /> Application Accepted By Date I-I—fArca Employee ID# q44 <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By fn Date ❑ WAIVER Received a <br /> Destruction Inspection B Date � ��L Constructed Well Depth ft ' <br /> COMMENTS Z —Z IQ"'0621 , <br /> PE SC Received ChecklfAmount Permit/Date Invoice# Well 1D# <br /> Codes [Jiro B Remitted Service Request# <br /> 1-2- 0:-5? 5`3 x <br /> EHD 43-02-006 MASTER WATER WELL PERMIT <br /> 12/6/2002 <br />