Laserfiche WebLink
WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AvE 3"FL-STOCKTON CA 95202-(209)46"20 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> JOSADDRESS 26931 SANTA RD. cimzIP TRACY <br /> CROSS STREET I I N N F R D_ APN 2—PARCEL SIZE-2 Y.Z y LAND USE APPLICATION# <br /> OWNER NAME GERALD ROBERTSON PHONE 835-5730 <br /> OWNER ADDRESS 29325 CHRISI.1AN RD. CrrV/STATFJZIP TRACY, CA 95304 <br /> CONTRACTOR HENNINGS BPOS. DRILLING CO. , INC. PHONE 545-1185 <br /> CONTRACTOR ADDRESS 3525 P E L A N D A L E AVE. C rr/STATFJZIP MODEST 0, CA 95356 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE .10 C-57 0 C-61 0 D-09 0 Other NUMBER EXPIRATION DATE 5-31-06 <br /> GEOGRAPHICALINFORMATION! Coordinate$ X Y Township Range_ Section <br /> INTENDED USE 013omestic/Private 0 Irrigation/Agricultural 0 Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> If diRerem from Ower <br /> net "tem ame Conwt Reme or Phore Number <br /> TYPE OF WORK EXNcw Well 0 Replacement Well 0 Well Altcration/Modification 0 Other <br /> 0Monitoring Well(s) #ofwells 0 Soil Boring(s) 0ofborinp OGeotechni"I 0ofbonnp <br /> 0 Out-Of--Service Well 0 Out-Of--Service Well Renewal 0 Cross-Connection Repair <br /> 0 New Pump 0 Pump Replacement 0 Plump Repair 1 <br /> WELL CONSTRUCTION <br /> Drilling Method)d Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point O Other <br /> Proposed Well Depth 500 ft Excavation 12 in diameter ❑Open Bottom XEX Gravel Pack/Gravel Size in diameter <br /> 0 Conductor Casing in diameter / Conductor Casing Depth it <br /> Well Casing Diameter 6 in Thickness/GaugdASTM Sched S D R 17 ❑Steel )UPlastic 0 Stainless Steel 0 Other <br /> Grout Seal Depth P S a 1 0 Neat Cement(94 IA bag/S-f 0 gal water) Usand Cement 10.3 sack mix/7 gal water <br /> O Bentonite(20%solids) 0 Manufacturer Spec%solids % Name 0 Specs on File 0 Specs Submitted <br /> Grout Placement Method EXPumped 0 Free Fall 0 Other 0 Retardant/Accelerator(name) t� <br /> �pj'yjr Installed By ❑Driller mp Contractor O Other '>> <br /> ❑Concrete Pedestal Dimensions:Width It Length ft Thick in 0 Christy Boa 0 Stove Pipe <br /> PUMP 0 Submersible ❑Turbine 0 Other HP Pump Set It Standing Water Level ft �G <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN ---AAA <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 1 AM IN COMPLIANCE WITH ALL !u" <br /> WORKERS COMPENSATION LAWS <br /> MINIMUM 24 HOUR ADVANCE NOTICre REQUIRED FOR INSPECTIONS <br /> SIGNEDfTLE SUPERVISOR DATE 5 <br /> 1 <br /> r <br /> _ 7 <br /> y 1 1 <br /> � r <br /> 1 I I - <br /> t <br /> t <br /> T <br /> D <br /> DEPA TMENT US ONLY / <br /> s �C'UU <br /> _ <br /> Applicattiol Accepted By - Date r CJ' Area Empl <br /> + Grout nspection By 1 Date - ❑ SPECIAL Well Per it / <br /> Pump nspection By Date ❑ WAIVER Reeeiv <br /> a <br /> I Constructe I Well Depth D ` <br /> COMMENTS 6P- 0 5'013v�/ OL-,) L oT C' <br /> PE SC Received Check#/ Amount Date Perm1U Invoke# Well]DO <br /> Codes Info By ash Remitted Service Request M <br /> va-tv « S7 3�s.✓v O ROoL133 �F dr'p,��laa3� <br /> EHD I3-02-W WELL PUMP PERMIT <br /> IfVrA 5 <br />