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WELUPUM� PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205-6232-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Joe ADDRESS 12501 Graves Rd Clrr/7rP Manteca 95336 n <br /> CROSS STREET W of Jack Tone Rd APN 228-070-03 PARCEL SIZE-)l LAND USE APPLICATION# 8 <br /> or <br /> OWNER NAME Rosa Farms LLC C/o Grant Van Duyn PHONE 209-595-2566 •`"• <br /> OWNER ADDRESS 12100 Graves Rd CITY/STATE/ZIP Manteca,CA 95336 <br /> CONTRACTOR Hennings Bros. Drillina Co_, Inc. PHONE 209-545-1185 (� <br /> CONTRACTOR ADDRESS 1930 Ladd Rd CITY/STATEmP Modesto,CA 95356 (7P <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE X C-57 C-61 D-09 Other NUMBER 290813 EXPIRATION DATE 05-31-2017 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section <br /> INTENDED USE Domestic/Private X Irrigation/Agricultural Industrial 7 Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner Water YStorn N81re uontact me or one Number <br /> TYPE OF WORK X New Well i Replacement Well -- Well Alteration/Modification i s Other <br /> Monitoring Well(s) #of wells :Soil Boring(s) #of borings 1 Geotechnical #of borings <br /> i Out-Of-Service Well - Out-Of-Service Well Renewal r l Cross-Connection Repair <br /> i New Pump i i Pump Replacement i Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method I Mud Rotary i i Air Rotary i Auger 'J Cable Tool i l Push Point x Other Reverse Rotary <br /> Proposed Well Depth 500 It Excavation 26 in diameter r Open Bottom Gravel Pack/Gravel Size No 6 in diameter <br /> *Conductor Casing ,30 in diameter �nnductor Casing DeP B� �✓" ft Sand Pack <br /> Well Casing Diameter 16 in T ickness/Gauge/ASTM Sched 1/4 X Steel _i Plastic r Stainless Steel i Other <br /> Grout Seal Dept qf5'Neat Cement(94 Ib bag15-10 gal water) x Sand Cement 10-3 sack mix/7 gal water <br /> I Bentonite(20%solids) i i Other <br /> Grout Placement Method i Pumped 1 Free Fall X Other Tremir+ rl Retardant/Accelerator(name) <br /> PEDESTAL Installed By i i Driller :x Pump Contractor i Other <br /> i Concrete Pedestal Dimensions:Width It Length It Thick in i Christy Box i i Stove Pipe <br /> PUMP Submersible'..i Turbine i Other HP Pump Set It Standing Water Level It <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 NOTLC Q`UIIREyD/nFOR INSPECTIONS C� <br /> SIGNED E �L. r DATE <br /> E�MENT <br /> E��FD <br /> EP p 6 2016 <br /> SMF c0UN <br /> 241 1 <br /> �EpAHTMFN'Y <br /> EPARTMENTI EONLY /GnJ'�j/} /y ,n <br /> W <br /> Application Accepte ate Area- —6—'�— Employee ID#, W <br /> Grout Inspection By Date / SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring 1 pection By Date Construct ell De th ft <br /> COMM NT60 <br /> E SC Received Chec Amount Date PermlU Invoice# Well ID# <br /> Codes Info B Remitted Service R uest# <br /> 1h 11b I (, i s 7s 3 R� q�l <br /> EHD 43-08 WELL/PUMP PERMIT <br /> 8/04/08 <br />