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lnr ? WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3"FL-STOCKTON CA 95202 -(209)468-3420 <br /> FADDRESS <br /> ABLE PERMIT CALL 209 953-7697 FOR I INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED I <br /> crry/zIP TRACY,CA 95304 <br /> 8 3 3 8 11. L I.d iJ E R D. n y`, g <br /> H RISi IAN R U. APN�����(V "✓ PARCEL SIZE LAND USE APPLICATIONBILL 8 STEPHANIE PRIC)STE PHONE833-9945 <br /> 8338 11. L I N N E RD. <br /> CITYISTATEIZIP TRACY C A 95304 <br /> CONTRACTOR <br /> 11E111.11NGS BROS. DRILLING CO. INC, PHONE 545-1185 <br /> CONTRACTOR ADDRESS 3525 P E L A 1d D n.L E ,�It E, Cm'/STATFJZIP o 0 D E S T U CA 95356 <br /> PHONE <br /> SUBCONTRACTOR <br /> CITY/STATE/ZIP <br /> SUBCONTRACTOR ADDRESS 5—3 1-0 8 <br /> LICENSE XY*-57 ElC-61 [3D-09 ❑Other <br /> NUMBER 2908 3 - EXPIRATION DATE <br /> Y, Township_ Range Section <br /> --- <br /> tGE(0)GIRLAPHICAL INFORMATION: Coordinates X <br /> Domestic/Private ❑Imgetion/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characurizaeion <br /> ❑Public Water Systemnt�r,arae or one umUdltferenr from OwnK ❑New Well Replacement Well ❑Well Alteration/Modification 'of <br /> ❑Other <br /> oofbonnp <br /> C3 Monitoring Wells) <br /> #of wells ❑Soil Boring(s) ❑Geotechnical <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ❑New Pump ❑Pump Replacement ❑PumZ.Repair <br /> W <br /> ELLRtI(TlON <br /> ❑Push Point ❑Other <br /> od !�1 Mud Rotary ❑Ait Rotary ❑Auger ❑Cable Tool Gravel Pack/Gravel Size in diameter <br /> ell Depth 2 5 0 ft Excavation14 Ir in diameter ❑Open Bonomft <br /> ❑Conductor Casing in diameter / Conductor Casing Depthng Diameter in ThicknesslGauge/ASTM Sched 16 0 C L ❑Steel l�Plastic ❑Stainless Steel O Other <br /> ❑Sand Cement sack mix/7 gal water <br /> Grout Seal Depth 200 ft [3 Neat Cement(94 lb bag/5-10 gal water) p Specs on File ❑Specs Submitted <br /> X M Bentonite(20%solids) ❑Manufacturer Spec%solids_% Name <br /> [3 Retardant/Accelerator(name) <br /> Grout Placement Method it Pumped ElFree Fall ❑Other <br /> e AI. Installed By ❑Driller Pump Contractor ❑ Other ft Thick in ❑Christy Bo: ❑Stove Pipe <br /> E:3 concrete Pedestal Dimensions:Width ft Length <br /> PUMP ❑Submersible E3 Turbine ❑Other <br /> Hp Pump Set ft Standing wat ' 41I -1 1 <br /> SAN <br /> -- BE <br /> f:LR77FY T{.},tiT-}-HAVE PnF�"ocn•ruts APPI.IrATiON AND THAT THE WORK WILL IF DONE IN ACCO TARED LICENSE IS <br /> JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY= ALL <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM 1N C 14NQE iVi��H <br /> WORKERS COMPENSATION LAWS. AN JOnui CC UU CC <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTION ENwll v" COUNTY <br /> 1 b T,T� SUPERVISOR � �-- <br /> SIGN!D —s <br /> - 60y <br /> - - <br /> . ... .. ., Date / Area 'Lsf4tplolD#��� - <br /> Application Accepted By <br /> Grout Inspection By <br /> Date C1 ❑ SPECIAL Well Permit <br /> Pump Inspection By <br /> Date— ❑ WAIVER Received <br /> Constructed Well Depth ft <br /> COMMENTS vv` <br /> PE SC Received 'Cheek#/ Amount Date Service R eR nest# Invoke# Well ID# <br /> Codes Info B Remitted <br /> o- 1bS �y5 s � G <br /> WELL PUMP PERMIT <br /> EHD 43-02-00 <br /> imno0s <br />