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WELL / PUMP PERMIT " <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH D... -RTMENT 304 E WEBER. r 3°0 FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE-PERMIT CALL 209 953-7697 FOR"INSPECTIONS " 5 �'" EXPI'RES"1'YEAR"FRUM'.DATE I53[1ED <br /> ART <br /> M <br /> S. aCH' UR BLVD. TRACY CITYIZIIP - _.,...m � <br /> JOB ADDRESS 18087 S - TRACY 95304 <br /> r� <br /> n r <br /> CROSS STREET DELTA APN 213-020-35 PARCEL SIZE vt J LAND USE APPLICATION# V <br /> OWNERNAME JOE &_MARY ROZA " n c/o QUALITY. ,SERVICES __ PHONE:. 838-7842 <br /> OWNER ADDRESS 27348 E. HWY 120 CITYISTATEIZIP <br /> CONTRACTOR HENNINGS 'EROS:"MILLING 'CO. INC. PHONE 545-�1185 <br /> CONTRACTOR ADDRESS 3525- PELANDALE' <br /> 'AVE CITYISTATVZIP MODESTO,CA 95356 �` <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP p <br /> LICENSE )ffC:-57' ❑C-61 ❑D-09 13 Other NUMBER 290813 EXPIRATION DATE 5-31-08 <br /> i <br /> GEOGRAPHICAL INFORMATION:_ Coordinates X < Y Township' Range Section <br /> INTENDED USE Domestic/Private ❑.Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring-. Cl Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Owner: Water System Name contact Nam or Pbone Num <br /> TYPE OF WORK LI(New Weil 13 Replacement Well ❑Well Alteration/Modification ❑,Other <br /> #of borings ❑Geotechnical #ofborings <br /> [3 Monitoring Well(s) #of wells ❑Soil Boring(s) , <br /> ❑.Out-Of-Service Well ❑•Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ❑New Pump ❑Pum '•R Iacement ❑Pump Repair <br /> WELL CONSTRUCTION <br /> Drilling Method EX Mud Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth ft Excavation 14 in diameter Q Open Bottom )P(Gravel Pack 1 Gravel Size in diameter <br /> ❑Con ucto Ing in diameter 1 Conductor Casing Depth ft <br /> Well Casing Diamete m. Thi kness/Gaugc.1ASTM Sched� 13-Steel 0 Plastic ❑Stainless Steen ❑Other <br /> Grout Seal Depth 0 ❑Neat Cement(94 lb bag I J-10 gal water) 0 Sand CementT sack mix 17 gal water <br /> �B tonite(20% tds) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Grout Placement Metho umped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller (I Pump Contractor ❑ Other <br /> ❑Concrete Pedestal Dimensions:Width ft' Length `+ ft Thick "`",: in ❑Christy Box 13 Stove Pipe <br /> PUMP ❑Submersible ❑Turbine ❑Other HP Pump Sete ft Standing -Water I':ev'ei' "'•ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE,DONE IN ACCORDANCE`'WITH SA"yV <br /> JOAQUIN COUNTY ORDINANCES, STATE"LAWS, AND RULES"AND REGULATIONS. I ALSO.;CERTIFY THAT MY REQUIRED.,LICENSE IS <br /> wtTw TH&CAL[FORNIA CONTRACTORS STATE LICENSE.BOA4tD'AP1D THAT 1 AM, C4NIPLIAIVCE WITH All", <br /> WORKERS COMPENSATION LAWS. V���� -- -" -- ----"--- <br /> MINIMUM 24 HOUR>ADVA CE OTIIC RF! EQUIRED FOR INSPECTIONS <br /> SIGNED IYfLE (SUPERVISOR DATE 112-27-07 <br /> ^t � <br /> !( <br /> i <br /> (i <br /> o H I <br /> 0 , CA <br /> n� <br /> r ' <br /> S <br /> N A. .M Nr <br /> E PfA R,T,M E N T U S E. ONLY " <br /> Application Accepted B • Date Area Employee ID <br /> Grout Inspection By f Date g _ 11 SPECIAL Well Permit <br /> Pump Inspection By "Date ❑' WAIVER:Received <br /> Constructed Well De th ft <br /> COMMENTS '.�.. <br /> PE SC Received Amount Date Permit/ . " <br /> Invoice# Well 1D#' <br /> Codes Info B Cash Remitted Service Request#1 <br /> Zo <br /> FUD 43-02-006 WELL PUMP PERMIT - <br /> I/27/20p5 �- <br />