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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3"FL-STOCKTON CA 95202 -(209)4611-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> s 1 <br /> JOS ADDRESS XX 31600 KOSTER RD. CrrvrLIP TRACY CA <br /> CROSSSTREET HWYY 33/DURHA14 FERRY RJ�PN 2SS —150 Za`/PARCELS12E S3 '19 LAND USE APPLICATION 0 � <br /> OWNER NAME <br /> NAT BACCHETTI PRONE 601-3768 <br /> OWNcitADDREsc 6245 W. CALIFORNIA CITY/STATT/ZIP TRACY, CA 95.104 <br /> CONTRACTOR HE14NINGS BROS. DRILLING CO., INC. PHONE 545-1185 <br /> CONTRACTORADDREAS 3525 PELANDALE AVE. CITY/STATE/ZIP MODESTO, CA 95356 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CrrY/STATEIZIP <br /> LICENSE 1xC-57 ❑C-61 ❑D-09 ❑Other NUMBER 290813 ExP1RATION DATi_5-31-08 <br /> GLOGRAPHICALINFORMATION: Coordinates X Y Township Rrngt Section <br /> INTENDED USE r Domestic/Privatc O Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Owner:WaterS n, <br /> ifdr2crem from erer ysrcm N.mcCo.—. ame or Phom. um <br /> TYPEOP WQRx CXNew Well ❑Replacement Well ❑Well Alteration/Modification DOther _ <br /> ❑Monitoring Well(s) #of wells ❑Soil Boring(s) ""b""" Q Geotechnical s orboriegt <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Crass-Connection Repair <br /> ❑New Pump ❑Pump Repi emcni ❑Pump Repair <br /> WELL CONSTRUCTION <br /> Drilling Method EXMud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Pcint ❑Other <br /> Proposed Well Depth 180 _ft Excavation- 12" in diameter O Open Bottom J Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing_m diameter / Conductor Casing Depth A <br /> )& <br /> Well Casing Diameter 6u in Thickness/Gauge/ASTNI Sched 16 CL ❑Steel )&Plastic ❑Stainless Steel OOther_ (A <br /> Groat Sea] Depth 00 ft O Neat Cement(94 1b bag/540gal wafer) O Sand Cement sack mix 17 gal water <br /> Mentonite(201/solids) 13Manufacturcr Spec%solids % Name_ O Specs on File O Specs Submitted q <br /> Grout Placement Method MI Pumped ❑Free Fall ❑Other_ ❑Retwilant/Accelerator(name) C <br /> PEDESTAL Installed By ❑Driller Ix Pump Contractor ❑ Other <br /> ❑Concrete Pedestal Dimensions:Width 9 Length _ft Thick in O Christy Box ❑Stove Pipe <br /> PUMP ❑Submersible ❑Turbinc ❑Other HP Pump Set ft Standing Water Level ft p <br /> 1 HEREBY CERTIFY THAT 1 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. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> yE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL e <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 24 HOUR ADVAN <br /> /O;PME REQUIRED FOR INSPECTIONS <br /> SIGNED T7 VJLd1. TTTLE SUPERVISOR DATE 9-26-07 <br /> J <br /> 4-7 <br /> 6 - J <br /> — — <br /> - <br /> r' W c <br /> N H N <br /> i - H <br /> L h G - <br /> Lf <br /> DEPARTMENT USE ONLY <br /> Application Accepted Ry � Date 1 U /5 r G / Area Emplovee ID# <br /> Grout Inspectior,8 G�'_'-G% - Date lG'//�L ❑- SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Constructed Well Depth ft <br /> COMMENTS t2c 0 i 1 G F -C c o =e'l <br /> PE SC Received Checict/ Amount Date Permit/ Invoice# Well JAN <br /> Codes Into B Cash Remitted rvice Request# <br /> �;�.c• (sem Ct— 3 �� <br />