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III <br />r <br />8968 T/AG <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 466-3420 <br />r curt-REFUNDA6LE rERMIT {.ALL (LU`,!) `J7J-1071 FOR INSPECTION5 CArimr* T TEAR FROM PATE ISSUED <br />JOB ADDRESS I qC q i Linne Road _ _ CITY/ZIP Trace, CA, g93o4 <br />CROSS STREET S Koster Road APIN �" rARCEL S12E64.'22 LAND USE APPLICATION # <br />f acres <br />NAME Hal Robertson PHONE 209-914-1382 <br />ADDRESS 3262 West Unne Road CITY/STATE/ZIP Tracy, CA, 95304 <br />ICTOR Eaton Drillinc Co.. Inc. PHONE 53o-662-6795 <br />LCTOR ADDRESS 20 West Kentucky Ave CITY/STATE/ZIP Woodland CA 95695 <br />ADDRESS <br />CRY/STATE/ZIP <br />PHONE <br />X C-57 i. C-61 D-09 i; Other Numoes 133783 EXPIRATION <br />GEOGRAPHICAL INFORMATION: Coordinates X37.69695 Y -121.3312 Township j3S Range -R6E s5 <br />INTENDED USE Domestic/Private x Irrigation/Agricultural Industrial - Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System <br />If different from Owner: Water byStern Name Gontac ame or Phone Numt>er T, <br />TYPE OF WORK x New Well Replacement Well Well Alteration/Modification <br />Monitoring Well(s) # of wells i Soil Boring(s) <br />Out -Of -Service Well L Out -Of -Service Well Renewa <br />x New Pump Pump ReDlacement 1 Pump Repair <br />Other <br />#of bonngs i Geotechnical <br />Cross -Connection Repair <br /># of <br />Drilling Method x Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br />Proposed Well Depth 600 ft Excavation 28 in diameter 1 Open Bottom x Gravel Pack/Gravel Size #8 in diameter <br />Conductor Casing None in diameter / Conductor Casing Depth ft <br />Well Casing Diameter 16 in Thickness/Gauge/ASTM Schad .250 X Steel i Plastic i Stainless Steel 1 Other <br />Grout Seal Depth 200 ft Neat Cement (94 lb bag/5-10 gal water) X Sand Cement lo.3 sk sack mix17 gal water li <br />- Bentonite (20% solids) - Other <br />Grout Placement Method x Pumped _ Free Fall _ Other Retardant / Accelerator (name) <br />PEDESTAL Installed By x Driller i Pump Contractor i Other <br />Concrete Pedestal iDimensions: Width –3—ft Length 3 ft Thick 6 in Christy Box Stove Pipe <br />rPump TBA Submersibles Turbine 7 Other HP Pump Set ft Standing Water Level ft <br />1 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 NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED ��Eaton Drilling Co.. Inc TITLE Manager _ DATE 7/8/2015 <br />DEPARTMENT U E ONLY <br />-I � p I <br />Application Accepted By 'V r (611 7 Area n l Employee ID# ` <br />Grout Inspection By Date n SPECIAL Well Permit <br />Pump Inspection By Date ❑ WAIVER Received <br />Soil Boring Inspection gy Dated 1 Constructed Well Depth R <br />COMMENTS !71[L vAi <br />� --- -----Ili <br />ED <br />U-TH <br />