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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205-6232-(209)468-3420 <br /> c <br /> NON-REFUNDABLE PERMIT CALL 209 953-7597 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> rn <br /> JOB ADDRESS21301 S.San Jose Rd CITY/ZIP Tr;;ry 95304 y <br /> CROSS STREETS Of W.Middle Rd APN 209-280-21 PARCEL$IZE�, LAND USE APPLICATION If A <br /> OWNER NAME Aaron���� 2 <br /> Smud ): 0-1,kOACAN PHONE 925-605-6762 i y <br /> OWNER ADDRESS 2135pQSan Jose Rd CITY/STATE/ZIP Tracy,CA 95304 ` <br /> CONTRACTOR Hennings Bros. Drilling Go., Inc. PHONE 209-545-1185 1✓ <br /> CONTRACTOR ADDRESS 1930 Ladd Rd CITY/STATEIZIP Modesto,CA 95356 <br /> SUBCONTRACTOR PHONE CJ�^ <br /> SUBCONTRACTOR ADDRESS CITY/STATEIZIP <br /> LICENSE K C-57 i C-61 i i D-09 i Other NUMBER 290813 EXPIRATION DATE 05/31/2018 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br /> INTENDED USE x Domestic/Private a Irrigation/Agricultural - Industrial Water Quality Monitoring -!Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner Water SyStern Name Contact Name or one um er <br /> TYPE OF WORK x New Well I_;Replacement Well I- Well Alteration/Modification -1 Other <br /> I Monitoring Well(s) #of wells ❑Soil Boring #of bodngs s) C Geotechnical #of borings <br /> I Out-Of-Service Well I Out-Of-Service Well Renewal ❑Crass-Connection Repair <br /> New Pump 7 Pump Replacement ❑Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> I <br /> Drilling Method k Mud Rotary I Air Rotary F Auger ❑Cable Tool U Push Point I Other <br /> Proposed Well Depth 95f1 ft Excavation 14 in diameter ❑Open Bottom 6t Gravel Pack/Gravel Size Nn 6 in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft Sand pack <br /> Well Casing Dia r in Thickness/Gauge/ASTM Sched CIDR96 i Steel X Plastic ❑Stainless Steel ❑Other <br /> Grout Seal pith 100 ft I Neat Cement(94 Ib bag/5-10 gal water) '-I Sand Cement sack mix17 gal water <br /> x Bentonite(20%solids) 1 Other <br /> Grout Placement od x Pumped 1 i Free Fall 1 1 Other j Retardant/Accelerator(name) <br /> PEDESTAL Installed By I I Driller x Pump Contractor -j Other <br /> -Concrete Pedestal Dimensions:Width ft Length ft Thick in I i Christy Box a Stove Pipe <br /> PUMP -Submersible u Turbine j Other HP Pump Set ft Standing Water Level ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE 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 IS <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 E REQUIRED FOR INSPECTIONS <br /> SIGNED TITLE Nt. In_ DATE <br /> L P4 <br /> RFCE�E T <br /> SAy10201? <br /> e<v <br /> ENVIR <br /> PE <br /> D PARTMENT USE ONLY <br /> Application Accepted By Date ( Area Employee 10# <br /> Grout Inspection By Date Z SPECIAL Well Permit <br /> Pump Inspection 131"" Date WAIVER Received <br /> Soil Boring Inspectibn By. Date Constructed Well Depth ft <br /> COM NTS < <br /> s <br /> PE SC Received heck Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B ash Remitted Service Request# VN <br /> sr <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 8104/08 <br />