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SAN JOAQUIN COUNTY ENv,RONMENTAL HEALTH DEPARTAI ENT lWLwe.ewn.na - _ NON-REFUNDABLE PERMIT CALL. 209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED y rJOBBRFSS 569 S. SANTA FE RD. CITY/ZIP riverbank . ca q5�7TREET S OF HENRY AFN7Yl-I�. PARCEL$12E I2' � 7NAME RANCH MARKET C/o Heide - PHONE 5451519 ADDRESS - 4226 GREENKNOLL RD. CITYISTATE21P SALIDA, CA 95368 CTOR HENNIgGS BROS. DRILLING CO. , INC. PHONE 545-1185 CONTRACTORADDRESS 9525 PFLANDALF AVE- CITYISTATE/ZIP MOOFSTO. CA 95356 SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITYISTATE/ZIP LICENSE ]77 C-57 DC-61 ❑D-09 DOther NUMBER 290'R1I EXPIRATION DATE _ _ GEOGRAPHICALINFORMATIQN: Coordinates X Y Township Range_ Section J� INTENDED USE D Domestic/Private D Irrigation/Agricultural D Industrial D Water Quality Monitoring D Soil Sampling/Characterization Publicater System IR .,Ius.—er: ur souc ...,PlE.e IIuacw TYPE OF WORK ONew Well a Replacement Weil D Well Alteration/Modification E3 Tot Hole ❑Other ❑Monitoring Wells) number ofwelh E3 Soil Borings) "'crorborinys [IGemechnical ^umbmofbodng: _ D Well Destruction D Out-Of-Service Well D Out-Of-Service Well Renewal D New Pum D Pump Replactareatt D Pam2 Re air D Cross-Canoectian Repair WELLCONSTRUCTION Drilling Method 10 Mud Rotary D Air Rotary D AAuaguelr�T 6o Cable Tool ❑Push Point ❑Other Proposed Well De th 250 ft Excavation�indiameter ❑Open Bottom ki Gravel Pack/Gravel Size in diameter i Conductor Cesing, I/e in diameter / Conductor Casing Depth 5a ft ' Well Casing Diameter 6 in Thickness/Gauge/ASTM Sched S D R 17 D Steel [A Plastic D Stainless Steel D Other Grout Seal Depth 200 ft D Neat Cement(94 lb hug/5-l0 gal water) 01 Sand Cement 1 G.3 tock mid 7 gal water D Bentonite(20%solids) D Manufacturer Spec%solids % Name DSpecs on File 13 Spent;Submitted Grout Placement Method bPumped ❑Free Fall 13 Other ❑Retardate/Acceleretor(name) PEDESTAL Installed By ❑Driller R(Pump Contractor 13 Other D Concrete Pedestal Dimensions: Width_ it Length_It Thick in 0Christy Box OStove Pipe PUMP ❑Submersible ❑Turbine DOthet HP Pump Set R Standing Water Level R WELL DESTRUCTION DOpen Bottom 0Gravel Pack ❑Untried ❑Other Well Diameter_in Total Depth ft Depth to Water ft D Casing to be Perforated fmm_it to_R Sealing Material O Neat Cement(941h hug/J-10gu/water) ❑Sand Cement sack mk/7 gal water D Bentonite Pellets D Beetonite(20%solids) ❑Manufacturer Spec%solids_% Name DSpecson File ❑Specs Submitted .. Placement Method D Pump D Free Fall D Other D Complete with g 1 HEREBY CERTIFY THAT I N VE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH,SAN JOAQUIN COUNTY ORDINANC S, STATE LA ,AND RULES AND,REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH. HE CALIFORN A CONTRACTORS STATE LICE%SE BOARD AND THAT I AM IN COMPLIANCE WITH ALL • WORKERS COMPENSATION LA S. MINIMUM 24 HOU ADVANCE OTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 SIGNED ` 5 ERE SUPERVI 11Na' ----DATE 12-12-03 I I a' 1 F OU M 7-1 Aav I 5 <. DEPARTMENT USE ONLY - ApplicationAccepted 2�. Date Z• a Employ.IDN sx 3g Grout Inspect. Date % SPECIAL Well Permit Pump Inspection By Date RIVER Received / (, 5r�' 0 FYI °P FILE COPY