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WELL/PUMP PERMIT <br /> SAN JOAQVIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WESER AVE 3"Ft,-swcicTON CA 95202 -(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECT-IONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> 5 y <br /> JOa ADORESS XX 31600 KOSTER RD` _ Crrv/ZIPI RACY <br /> CROSS STREET HWYY 33/DURHAII FERRY RQP.c 2-5S —JAG• 2-Sl PARCKLSIZE LAND USE APPLICATION N A <br /> OWNER NAME NAT BACCHETTI PHONE. 601-3768 <br /> OWNERADDRESS 6245 W. CALIFORNIA CITY/STATE/ZIP TRACY, CA 95304 <br /> CONTRACTOR HENNINGS BROS. DRILLING CO., INC. PHONE 545-1185 <br /> CONTRACTORADDe,,&t 3525 PELANDALE AVE. CITYISTATU71P MODESTO, CA 95356 <br /> S1IRCONTRACTOR <br /> SLBCONTRACTOR ADDRESS _ _ CrTYlSTATE/ZIP, <br /> 1 LICENSE EXC-57 ❑C-61 ❑D-09 ❑Other NCMaER 240813 EXPIRATION DAN'S: 5-31-08 <br /> GEOGRAPHICAL INFOR.HATION: Coordinates X _ Y Township_ RAnge Section_ <br /> INTENDED USE XI Domeitic!Private ❑Irrigation/Agricultuml ❑Industrial ❑Water Quality Monitoring f]Soil Sampling/Characterization <br /> ❑Public Water System _ <br /> If Wrerem from 0— arer y.—NYme -tact .-� oneN—b. <br /> TYPE OF WORK y(Nc-Well ❑RepLoemeni Well ❑Well Alteration/Modification ❑Other <br /> O Monitoring Wdl(s) _#of webs ❑Soil BoringY of bon nip 13s} Geotad M of barirphnic <br /> ❑Out-Of-Semcc Well ❑Out-Of•Service Well Rencwel ❑Cross-Connection Repair <br /> ❑New Pump O Pump Repia.ement ❑Pump Repair <br /> WELT.CONST ll(TION <br /> Drilling Method CXMud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Pcint ❑other <br /> Proposed Well Depth 180 ft Excavation_ 1211 in diameter ❑Open Bottom b-GraYel Pack/Gravel Size—in diameter <br /> ❑Conductor(:asing_ indiameeer Conductor Casing Depth ____ft <br /> Well Casing Diameter 6" in Thickncss/Gaug41ASTVI Sched 1 6 L_ ❑Steel M Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth 1 DD 11 ❑Neat Cement(94 lb bug i S-!0 gal water) ❑Sand Cement_ _suck nein/7 gal water <br /> )003emonite(20°1,solids) ❑Manufacturer Spec%solids % Name_ ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method 6 Pumped ❑Free Fall ❑Other ❑Rcta!dant/Accelerator(name) <br /> Rgocaa Installed By ❑Driller IX Pump Contractor ❑ Other h <br /> 13Concrete Pedestal Dimensions*Width 9 Length_.a ft Thick in ❑Christy Boa ❑Store Pipe <br /> PUMP ❑Submersible ❑Turbinc ❑Other _HP Pump Set_ ft Standing Water Level fl Q <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN Y' <br /> JOAQUIN COUNTY ORDINANCES,STATE LAW'S,AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS T7j <br /> -GWA0X6Xi-AhM..eL1IYE.WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. ----'------ -- __ <br /> MINIMUM 24 HOUR ADVAN PYIPTCE REQUIRED FOR INSPECTIONS <br /> SIGNED �3tei. Trrr.s SUPERVISOR DATE 9-26-07 <br /> s <br /> 4 '1 <br /> 7 - <br /> IN <br /> - E <br /> ` / h N R N - <br /> _ j N <br /> Ll- <br /> - <br /> 64{} <br /> DEPARTMENT USE ONLY <br /> Application Accepted By ( Date t U IO Arca Employee ID# L �S[" ' <br /> Grout lnspecdo*.D, •%'_TCS - Ualc !G 11C�'� 11SPECIAL Well Permit <br /> T <br /> Pump lnspectron By Date ❑ WAIVER Received <br /> Constructed Well Depth It <br /> COMMENTS 0C O c a r..6 f ,2E C-o e3 <br /> PE SC Received ChecluY/ Amount Permltl <br /> Code: Info B Cash Remitted Dare nice R ues[III <br /> I rvnlre M Well lA+e <br /> 4,�:c, 1:SL Cs >2-= ti u S 5 -2 Q 3� <br /> EXD4]-02.00e WELL PUMP PERMIT <br /> 1:]7RW3 <br />