Laserfiche WebLink
�•, WELL/PUMP PERMIT <br /> StiN lDAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E Wr.RER AVE 3"FIL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 31411 KASSON RD. CITY/zIP TRACY <br /> CROSS.STREET DURHAM FERRY RD. APN •ZSS- 3 40-VfPARCEL SIZE `+ • <br /> _ LAND USL APPLICATION# <br /> OWNERNAMEJOHN PETLANSKY c/o BOB WILLIAMS PHONE Ent-3g0g <br /> OWNER ADDRESS 11142 RAINES RD. _ Cn•v/SrATE/ZIP PATTERSON, CA 953fi2 <br /> CONTRACTOR HENNINGS BROS. DRILLING CO., INC. PHONE 545-1185 <br /> CONTRACTOR ADDRESS 3525 PELANDALE AVE. CRY/STATEIZIP <br /> SUBCONTRACTOR PHONE S/ 7 <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE [W-57 ❑C-61 ❑D-09 ❑Other NUMBER 280$1 EXPIRATION DATE 5-31-08 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y "township Range Section <br /> INTENDED USE ❑Domesticil`rivate rrigation/Agdcultural ❑industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System _._. .. <br /> If ditTerem from rut: VParu.ystem Name Cmact —a one Nu r <br /> TYPE OF WORK IN New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> ❑Monitoring Well(s) #of wells ❑Soil Bonng(s) s of borings ❑Geotechnical s Mh—p <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ❑New PuTp ❑Pump Replacement ❑Pump Repair <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rota 1 r,1 Rotary ❑Auger ❑Cable Teal ❑Push Point IX other_Reverse Rotary <br /> Proposed Well Depth z -ft E valion 26" in diameter ❑Op -Bo m IX Gravel Pack/Gravel Size 6x8 in diameter LAJ <br /> IA Conductor Casing. in diameter i Conductor Casing Depth 50 n CEMENTED IN <br /> 411 <br /> Well Casing Diamet in Thic nesa/Gauge/ASTM Sched t14g6 Z S[ Plastic ❑Stainless Steel ❑Other_ <br /> Grout Sea] Depth' !)U ❑Neat Cement(94!h hng/5-/0 gal wolrrJc ❑Oct"fin sack mix 17 gal water <br /> 13m� <br /> Bemites /solids) ❑Manufacturer Spec%solids % NaONDUC''"" Specs on File ❑Specs Submitted <br /> Grout Placement Method [A Pumped ❑Fra Fall ❑Other ❑Retardant!Accelerator(name) <br /> EDiSTAI. Installed By ❑Driller MumpConuactor ❑ Other <br /> ❑Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level_ ft <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN e` <br /> JOAQUIN COUNTY ORDINANCES. STATE LAW'S,AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS Z <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> Wl3' MSCOMPENSATIONILAWS._. R <br /> MI IMUM 2 I I HOUR DVANC.f NO <br /> TIC _Q RE6TOR INSPECTIONS- <br /> SIGNED ` ! TIL SUPERVI&OR DATE9-8-07 <br /> e <br /> fl <br /> D <br /> U <br /> Ka <br /> O <br /> N <br /> s n p U <br /> p A <br /> DEPARTMENT USE ONLY `- <br /> Application Accepted By ate t'l Arca Fmployee ID# �� <br /> Grout Inspection By_ ate D SPECIAL Well Permit <br /> Pump inspection By Datc O WAIVER Received <br /> Constructed Well pth D <br /> CU/ N S 21r /tr / - <br /> .Z , <br /> PE' SC Received ec Anlount Date PermiU Invoice# Well IDN <br /> Codes Into By ash Remitted Service Request# <br /> !8v > 32S.Lt-0 <br /> END 43-02.006 WELL PUMP PERMIT <br /> Ir17,R005 <br />