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WELL l PUMP PERMIT <br /> SAN J AQum COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3—PL-STOCKTON'CA 95202 -(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> rn <br /> JOB ADDRESS 7330 W. DELTA AVE. _ - ._ crrv//z^zIP . TRACY, CA 95304 _ <br /> CRMSIREET �_{ TTr�L`E APN 213-020-39 PARCELSIZF. t'V LAND USE APPLICATION# A <br /> OWNER NAME JOHN PEREIRA PHONF. 481-2886 <br /> OWNERADDw..S 15673 W. REDONDO DR. _ CITY/STATVZIP TRACY, CA 95304 <br /> CONTRACTOR HENNINGS BROS. DRILLING CO., INC. PHONE 545-1185 <br /> CONTRACTOR ADDRESS 3525 PELANDALE '!AVE. CITY/STATVZIP MODESTO,CA 95356 <br /> SUBCONTRACTOR PHONE <br /> SUDCONTRACTUR ADDRESS_ _ CITY/STATFJZrP <br /> LICENSE EXC-57 ❑C-61 ❑D-09 O Othcr NUMBER 91181 EXPIRAnON DATE 5-31-08 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Towashlp Range _ Section_ <br /> INTENDED US e Ix Domestic/Private O Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring 0 Soil Sampling/Chamcterization <br /> Cl Public Water System _ <br /> Ifdifferentfrom Owner .- yuem,emc 7- N— , um <br /> TYPEOP WORK 1XNew Well ❑Replacement Well ❑Well AlterationModitication ❑Other - <br /> O Monitoring Well(s) #of wells O Soil Bonng(s) #orbonng, O Geotechnical v ofbonnp <br /> ❑Out-Of-Service Well ❑Out-Of--Service Well Renewal ❑Cross-Connection Repair 1 <br /> ❑New Pump O Pump Re tla.;ement ❑Pump Repair 'V <br /> WELL CONSTRUCTION lIV <br /> vJ <br /> Drilling Method [Mud Rctary O Aur Rotary O Auger O Cable Tool ❑push Print � ❑Other O <br /> Proposed Well Depth Excavation 14 in diameter O Open Bottom Ly1•Gravel Pack/Gravel Size in diameter <br /> OCo ctorCasing in diameter / Conductor Casing Depth <br /> Well Csslog Diameter 8 in Thickncss/GauWJASTM Sched 160CL ❑Steel (Aplastic ❑Stainless Steel OOther <br /> Grout Seal Depth 100 ft Cl Neat Cement(44 Ib bag/5-10 gal wafer) ❑Sand Cement sack mix/7 gal water U <br /> a(Bentonite(20%solids) O Manufacturer Spec%solids % Narne_ ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method )v Pumped O Frec Fall ❑Other_ ❑Retardant/Acccicramr(name) ..J <br /> PEDESTAL Installed By O Driller IX Pump Contractor ❑ Other �I <br /> ❑Conernte Pedestal Dlmeasloaa:Width A Length fl Thick in O Christy Bos ❑Stave Pipe ..tP <br /> PUMP ❑Submersible O Tuthioe ❑Other HP---Pump Set ft Standing Water Level _ ft <br /> HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN C. <br /> JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS (Tl <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTTOTCYORS STATTLA I NSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS <br /> MINIMUM 24—HOUR ADVANf F N>wkjr'r orn,rr...... .. --•� --r� � <br /> sIGNED� 7 ins p 6 _ <br /> Q W t n <br /> 0 N <br /> _ ' (30 <br /> 00 N t>< p <br /> Iqn N to 7 <br /> cA 0 L v <br /> 9 9 <br /> C <br /> 401 <br /> 20p <br /> Ery°oNlN <br /> Rc/N <br /> CAuPlyr <br /> Y' c a <br /> Lf 5-5 <br /> Application Accepted By a` Dain/ G' Area Employee ID# J <br /> Grout Irtspec6an By Date ❑ SPECIAL Well Permit <br /> Pump Inspect,ort By -__ Date-- ❑ WAIVER Received <br /> Constructed Well Depth R <br /> COMME F- - e'Zc— <br /> PE SC Received Chet 1 Amount Date Invoice# Well 11114 <br /> Codec Info B Itemitted ervice Request to <br /> EHn 4mmo6 WELL PUMP PERMIT <br /> 112712005 <br />