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loS2655S <br /> SAN JDAOUIN COUNTY ENVIRDNMENTAL HEALTH DEPT WELL/PUMP PERMIT <br /> 1866 East Hazelton Avenue-STOCKTON CA 95205-6232-(209)4684420 <br /> NON-REFUNDABt E PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Joe ADDRESS .�k_jone Rd w ct cid ZA <br /> CrTYILP Stncktnn 85915 <br /> D <br /> CROSS STREET S.of Mariposa Rd APN 181-170_09 PARCEL SRE LAND USE APPUCATION# o <br /> 0 <br /> PHONE 639-1583 <br /> CITY/STATE1ZP Stockton CA 95215 <br /> CONTRACTOR Hennings Bros.Drilling Co Inc PHONE 209-545-1185 <br /> I <br /> CONTRACTOR ADDRESS_2525 Pelandale Ave C-1STATE21P MQdeato CA 95356 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTArEop <br /> LICENSE X C-57 C-6/ D-09 Other NUMBER ERPIRATION DATE 05-31-2016 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br /> IKTENDED USE <br /> I DIf oalmKeereWnGt hem Owencr X <br /> Imgation/Agnalluraaler ys Ienmdmae l �WatefiryrPublic Water System mSeampling/Charactenzation <br /> a me u <br /> I <br /> TYPE OF WORK X New Well Replacement Well Well Alleration/BtodlfirAlion Other <br /> Monitoring Weil(s) 0 o wells Sal Bonn9( 1 s 1111 hOnn° Geotechrtiu! <br /> ` ser borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Crass-Connexion Repair <br /> __ New Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary Auger Cable Tad Push Pant X Other Reverese Ratnry ari�� <br /> Proposed Well Depth 500 R Excavation 26 in diameter Open Bottom X Gravel Pack/Gravel Size 6/8 sand pm uimteter <br /> X Conductor Casing 30 in diameter I Conductor Casing Depth SD ft <br /> Well Casing Diameter 16 in Thickness/Gauge/ASTM Sched 1/4,n X Steel Plastic Stainless Steel Other <br /> Grout Seal Depth 50 ft Neat Cement(94/D Dag/5-10 gal wateo Sand Cement sack mrxq gal water <br /> Bentonile(20%solids) X Outer 30'r 50'can cemented In wnh 10.3 sale cement <br /> Grout Placement Method X Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEOE3TAk Installed By Driller X Pump Con"C10'r Other <br /> Concrete Pedestal Dimensions:Wdth ft Length ft Thiele in t Christy Box Stove Pipe <br /> Pu Submersible Turbine Other HP Pump Set ft Standing Water Level fl <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 /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> U R�U/IJR/E'D FOR INSPECTIONS / <br /> SIGNED E I�iC.�C/� r DATE !O <br /> f <br /> I <br /> �- <br /> A <br /> l <br /> I <br /> i <br /> X 0V <br /> /77 <br /> I <br /> DEPARTMENT USE ONLY <br /> ' Application Accepted By Dale Area Employee IDS <br /> Grout Inspection By Date SPECIAL Well Permit <br /> iPump inspection By Date WAIVER Received <br /> Sod Bonng Inspection By Oate Constructed Well Depth__ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Permit/ <br /> Codes Info B Cash Remitted Date Service Re uest# Invoice# Well IDS <br /> EHO 43-06 <br /> WELL HUMP PERNR <br /> af0lga <br />