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WELL/PUMP PERMIT J/ 8j- <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3f°FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> H <br /> JOB ADDRESS 8501 W. SCHULTE RD. cITY/zIP TRACY <br /> Hu B r�i{ Al-1� o <br /> CROSS STREET Ma cARCIHRYSAR9 RDSAPN a2SC -j7C-OI PARCELSIZE o LAND USE APPLICATION# �.4-0300 f3Z m <br /> CMS <br /> OWNER NAME MATTO :� _61 <br /> S c/o RIMROCK INC. PHONE Rc, 611 <br /> OWNER ADDRESS- 28290 S. BANTA RD. CITY/STATE/ZIP TRACY, CA 95304 <br /> CONTRACTOR HENNINGS BROS. DRILLING CO. , INC. PHONE 545-1185 <br /> CONTRACTOR ADDRESS 3525 P E L A N D A L E AVE. CITY/STATFJZIP M O D E S T O CA 95356 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE )bv,(--57 ❑C-61 ❑D-09 ❑Other NUMBER EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION! Coordinates X - Y Township Range Section <br /> INTENDED USE 6 Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Charactenration <br /> ❑Public Water System <br /> If diiTe I from Ownn. .I., yuc .me onuct ame or one um r <br /> TYPE OF WORK b New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other <br /> ❑Monitoring Well(s)_#ofwells ❑Soil Boring(s) aufbormp ❑Geotechnical sof boring <br /> ❑Well Destruction ❑Out-0f-Service Well ❑Out-Of-Service Well Renewal <br /> ❑New Pump ❑Pump Replacement ❑Pump Repair ❑Cross-Connection Repair <br /> WELL CONSTRUCTION <br /> Drilling Method lb Mud Rotary 5 1,1 Af Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth W _ft Excavation 12 in diameter ❑Open Bottom Ii Gravel Pack/Gravel Size in diameter <br /> _❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter 6 in Thickness/Gauge/ASTM Schcd 16 D C L ❑Steel IX Plastic ❑Stainless Steel ❑Other -1 <br /> Grout Seal Depth 200 ft ❑Neat Cement(94/b hug/J-/0gul water) ❑Sand Cement sack mix/7 gal water <br /> 10 Bentonite(200/6 solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method 6 Pumped El Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By 0 Driller Pump Contractor ❑Other �- <br /> ❑Concrete Pedestal Dimensions: Width_ ft Length_ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set Il Standing Water Level ft <br /> n <br /> I HEREBY CERTIFY THAT 1 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 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> _ <br /> MINIMUM 24 HOUR ADVANCE 0T ICE REQUIRED FOR INSPEC'TIONS 6-24-05 <br /> SIGNED\'u1\ 1ph, `AJ-��.. I TLE SUPERVISOR n.TV 19 X 19 <br /> Q <br /> i <br /> r <br /> z D' <br /> DEPARTMENT USE ONLY ! S G <br /> — — <br /> f+PPlicationAcceptedBy---- _ /�JL/ Date Area Employee <br /> Grout Inspection By V 1 C.T,HiQ 1►t(e'e4 ri>-laq Date S ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received - <br /> Destruction Inspection By Date Constructed Well Depth ft <br /> COMMENTS NF—L) L-rT c;F Q-Ecur°A -03-/3Z <br /> PE SC Received Chec Amount Date Permit/ invoice# Well IDN <br /> Codes Info B Cash Remitted Service Request# <br /> 143Hry 15v zzs.eZ, 00 29 14.tGn0,;26-��5 <br /> WELL PUMP PERMIT <br />