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WELL / PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH 191896TMENT 304 E WEBEINwe:3°°FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED rn JOB ADDRESS 26955 S. HANSEN RD. CITY/ZIP TRACY, 95376 CROSS STREET SHULTE RD. ApN 2�� /(0O y PARCEL SIZE7, fE. OWNER NAME DAVID WEAVER PHONE 836-0501 OWNER ADDRESS 26955 S. HANSEN RD. CITY/STATE/ZIP TRACY, CA. 95376 CONTRACTOR NOACK PHONE 948-8817 CONTRACTOR ADDRESS 4500 E. FREMONT ST. CITY/STATE/ZIP STOCKTON, CA. 95215 SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE 11C-57 0C-61 0D-09 [3 Other NUMBER 504513 EXPIRATIONDATE 01105 GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range_ Section INTENDED USE 1%Domestic/Private ❑Imgation/Agricultural ❑Industrial- ❑Water Quality Monitoring ❑Soil Sampling/Characterization •Public Water System If different from Ownm: waver system Nam C.Mect NM.or Phone Nu.Mr TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Aiteration/Modiflcation ❑Test Hole ❑Other ❑Monitoring Well(s) number of wells ❑Soil Boring(s) number of borings 0Geotechnical number of boring 11-1 ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑New Pump ❑Pump Replacement )b Pump Repair ❑Cross-Connection Repair WELL CONSTRUCTION DriRing Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other Proposed Well Depth ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter ❑Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter _in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other Grout Seal Depth ft ❑Neat Cement(94 ib bag/5.10 gal water) ❑Sand Cement sack mix/7 gal water ❑Bentonite(20a/solids) ❑Manufacturer Spec°/solids—% Name ❑Specs on File ❑Specs Submitted Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed By ❑Driller ❑Pump Contractor O Other ❑Concrete Pedestal Dimensions: Width_ ft Length_ft Thick in ❑Christy Box ❑Stove Pipe PUMP IX Submersible ❑Turbine ❑Other HP_lh_ Pump Set 360 ft Standing Water Level 216 ft WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other Well Diameter in Total Depth ft Depth to Water ft ❑Casing to be Perforated from ft to tl Sealing Material ❑Neat Cement(94 1h bag/5-10gal water) ❑Sand Cement sack mix/7 gal water ❑Bentonite Pellets ❑Bentonite(20%solids) ❑Manufacturer Spec%solids-% Name ❑Specs on File ❑Specs Submitted Placement Method ❑Pumped ❑Free Fall ❑Other ❑Complete with Mushroom Cap ft below grade ❑Complete to Existing Surface Pad 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MI MUM 24 OUR ADV CE NOTICE REQUIRED FOR INSPECTIONS—PLEASE CALL(209)953-7697 SIGNEDr TITLE RETAIL SALES DATE 30 NOV. 2003 YT D LJ NULUN AL Ell I —r-T L—LI I HE kLT DPRT 4EI,T Application Accepted By Date Area a I ' Employee ID# y Grout Inspection By Dete 11 SPECIAL Well Permit Pump Inspection By� � Date / Or/ ❑ WAIVER Received Destruction Inspection By Date Constructed Well Depth ft COMMENTS PE '*Sc Received hec Amount Date Permit/ Invoice# Well ID# Codes Info By Cash Remitted Service Request# d a Oc�31�5O L D EHD43-02-OD6 6( / MASTER WATER WELL PERMIT 12/62002