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0, C-0 <br />WELL / PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3a° FL - STOCKTON CA 95202 - (209) 468-3420 <br />INV1N-KEFUNDABLE YERMIT UALL (209) 955-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br />3- <br />-Joe ADDRESS 32705 Koster Rd. �� CITY/zip Tracy <br />CROSS STREET S O u t h of H w V 33 APN _� ' J5�1~���'7 ✓! . PARCEL SIZE LAND USE APPLICATION # <br />OwNERNAME John & Annamarie Lara PHONE 321-3541 <br />OWNER ADDRESS P.O. Box 795 CITY/STATE/ZIP Westley, CA 95387 <br />CONTRACTOR Hennings Bros. Drilling Co.,Inc. PHONE 545-1185 <br />CONTRACTOR ADDRESS 3525 P e l a n d d l e Ave. CITY/STATErz,P Modesto, CA 95356 <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS <br />LICENSE I1 C-57 ❑ C-61 O D-09 ❑ Other <br />CITY/STATE/ZIP <br />NUMBER 2 9 0 (J 13 EXPIRATION DATE 5/31/06 <br />GEOGRAPHICAL INPORMATION: Coordinates X Y Township Range Section <br />yTENDED USE Domestic/Ptivate ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br />❑ Public Water System <br />If diR rent from Owner. atm Syne. ame Conwt are or Phone Numb= <br />WEOF WORK dNew Well ❑ RCDI8Cerl1ent Well ❑ Well Alteration[Modificatlon ❑ other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) sof boring, ❑ Geotechnical s of 1'nnng' <br />❑ Out -0f --Service Well ❑ Out -0f -Service Well Renewal O Cross -Connection Repair <br />❑ New PumD ❑ PumD Replacement ❑ Pumn Repair <br />Drilling Method Cl. Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth 2 2 C R Excavation in diameter ❑ Open Bottom O(Gravel Pack / Gravel Size N O F� in diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _8 in Thickness/Gauge/ASTM Sched 16 0 (' 1 ❑ Steel ['Plastic ❑ Stainless Steel ❑ Other <br />Grout Sed Depth 1 0 0 ft ❑ Neat Cement (94 1b bag / 5-10 gal water) ❑ Sand Cement sack mir / 7 gal water <br />EY Bentonite (20% solids) ❑ Manufacturer Spec % solids _ % Name ❑ Specs on File ❑ Specs Submitted <br />Grout Placement Method IX Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller Pump Contractor ❑ Other <br />❑ Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑ Christy Boz ❑ Stove Pipe <br />PI�Mp ❑ Submersible ❑ Turbine ❑ Other HP Pump Set ft Standing Water Level ft <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. 1 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 />&IN�24RADNCE NOTICE REQUIRED FOR INSPECTIONS <br />SICN "- TITLE ( V . P . DATE 9/16/05 <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Constructed Well Depth <br />COMMENTS <br />DEPARTMENT U ENLY <br />Date OS <br />Date <br />Date <br />if, <br />a <br />°o <br />J <br />0 <br />ul <br />ON <br />Area Employee ID#400051-7 <br />0'0 E IAL Well Permit / <br />13WAIVER Received 13 WPJ <br />PE SC Received - <br />Codes Into By Cash <br />Amount Date Permit/ Invoice # Well IDN <br />Remitted Service Request# <br />L S <br />of L 0 n. I ce ,�2&riCJ <br />EMD 43-03-W6 WELL PUMP PERMIT <br />1/27/2005 <br />