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WELL I PUMP PERMIT <br /> F'SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT y 304 E WEBER AVE 3"FL-STOCKTON CA 9520 J09)468-3420 <br /> NON-REFUNDABLZ PERMIT CALL 4209)9a3-17697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOBADDREss 33700 S. KOSTER RD. iTWZIP TRACY 95304 <br /> Y <br /> CRO55 STREET H 4J Y 1 3 2 _APN 2 5 5-16 0-0 2 7 PARCEL SIZE LAND USE APPLICATION# m <br /> 0 <br /> OWNER NAME ED THOt4I NG a SONS PHONE 835-2792 <br /> wNER ADDRESS 33600 S. KOSTER RD. CITYISTATFIZIP TRACY, CA 95304 <br /> +CONTRACTOR HENNINGS BROS. DRILLING CO. , INC. - PHONE 545-1185 <br /> CONTRACTOR ADDRESS 3525 PELANDALI AUT. CITVISTATIE MODEST', CA 95356 <br /> UBCONTRACTOR PHONE <br /> )..CON TRACT OR ADDRESS f CITY"TATEIZIP <br /> LICENSE PC-57 - ❑C-61 ❑D-99 ❑Other NUMBER 2 9-0-8-t3-- EXPIRATION DATE - - <br /> fEOGRAPHICALINFORMATION: Coordinates X Y Township Range Section_ <br /> i INTENDED USE IN Domestic/Private ❑IrrigasionlAgricuitural ❑Industrial C]Water Quality Monitoring ❑Soil Sampling/Characterization 1 l j <br /> ❑Public Water System 1 v <br /> irdifrerem from weer Water "Iem Name "act Nme or Phone Number ,5 <br /> FYPEOFWORK 111 New Well ❑Replacement Well 0 Well AlteralionlModiflcation ❑Test Hole ❑Other <br /> ❑Monitoring Well(s) p of wells ❑Soil Boring(s) paf6oriay #_ <br /> bonnyT <br /> ❑Geotechnical <br /> ❑Well Destruction ❑Out-O£-Service Well ❑Out-OF-Servicc Well Renewal V <br /> 0 New Pump ❑Pump Replacement ❑Pump Repair ❑Cross-Connection R air <br />' WELLCONSTRUCTION <br /> Drilling Method N Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other - <br /> Proposed Wel! Depth 2 3 0 R Excavation 12 II in diameter ❑Open Bottom Q(1 Gravel Pack!Gravel Size in diameter <br /> U❑Conductor Casing in diameter / Conductor Casing Depth R <br /> Well Casing Diameter 6 n ThicknessfGaugelASTM Sched 16 0 C L ❑Steel IX Plastic ❑Stainless Steel ❑Other <br /> (i-••I• Grout Seal Depth 1 0 R ❑Neat Cement(94 th hag 15-I0gal ware) ❑Sand Cement xaek mix/7 gal water <br /> IN Bentonite(26%solids) ❑Manufacturer Spec%solids a/ Name ❑Specs on File Q Specs Submitted <br /> 'G <br /> rout Pent Method IN Pumped ❑Free Fal l ❑Other ❑Retardans!Accelerator(name) <br /> Installed By ❑Driller [.x Pump Contractor i7 Other <br /> ❑Concrete Pedestal Dimensions: Width H Length R Thick in ❑Christy Box ❑Stove Pipe <br /> ❑Submersible ❑Turbine ❑Other HP Pump Set R Standing Water Levet R <br /> I 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 /> F <br /> RRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> ORKERS COMPENSATION LAWS. - <br /> `, {MINIMUM 24 HOUR ADVANC NO-TICE REQUIRED FOR INSPECTIONS <br /> SIGNED '[ - V - ^' X TITLE SUPERVISOR DATE 3-16-05 <br /> F.- <br /> 1N <br /> IF w - <br /> a U <br /> j # r <br /> Y <br /> I-P11 <br /> 4++ <br /> I � w <br /> i C <br /> PARTME NT U E ONLY <br /> Fl Application Accepted Bye r I J% +• -�--- Date , _ C%< Area�_ Employee ID <br /> Dater a © SPECIAL Well I'¢rrolt <br /> Grout Inspection By�-X7. � /..'•r� ^1 sf.�.'_ <br /> Pump Inspection By Date 0 WAIVER Received <br /> 1 Destructionft <br /> Inspection By Date Constructed Well Depth <br /> L <br /> "'COMMENTS — --2OL­ /�/ <br /> : - ' % <br /> 1/' '! .j'r` / !'i-rr�)r',ic- //l%f'f(%�uAi`^ ;r{uti•; <br /> PE SC Received Check#! Amount - Permit! <br /> Date Invoice# We111D# <br /> Codes Info By ash Remitted Service Regues(# <br /> �, l yS33 7Z <br /> I h <br /> �}EHD 44-OZ-nnfi WELL PUMP PERMIT <br /> RrfJ04 <br />