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