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i 18975 T/AG <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMEKTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-'716,97 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Joe ADDRESS 1 D L ->.- w�GkiLI.Er� 9 a <br /> CRY/LP TRACY,CA,95376 m <br /> CROSS STREET BETHANY RD APN 209-310-11 PARCEL31ZE-8,12 LAND USE APPLICATION# <br /> acres <br /> OWNER NAME WESTSIDE IRRIGATION DISTRICT 20 a <br /> PHONE 9-479-2116 DAVE KAISER <br /> fa OWNER ADDREss ig2o S TRACY BLVD CRY/STATE/LP TRACY,CA.95376 <br /> CONTRACTOR Eaton Drilling Co..Inc. PHONE 530-662-67n5 <br /> CONTRACTOR ADDRESS 20 West Kentucky Ave CrrY/STATE/LP Woodland CA 9095 <br /> w <br /> 4 SUBCONTRACTOR PHONE <br /> W <br /> Q SUBCONTRACTOR ADDRESS CRY/STATE/ZIP <br /> x <br /> LICENSE K C-57 F C-61 ,D-09 Other NUMBER 133783 EXPIRATION DATE 7/31/2016 <br /> GEOGRAPHICAL INFORMATION: Coordinates X ! '99�44lDT-I Z 1,556 YYlghip TzS Range R4E Section S30 <br /> fx <br /> INTENDED Use Domestic/Private Irrigation/Agricultural _ Industrial L Water Quality Monitoring -Sall Sampling/Characterization <br /> Public Water System <br /> If different from Owner: water 5Y81em Name a ame or one um r <br /> {Q{z7 <br /> 2 TYPE OF WORT iw Well Replacement Well L Well Alteration/Modification L Other <br /> Monitoring Well(s) #of wells i Soil Boring(s) #of borings i Geotechnical #of borings <br /> Out-Of-Service Well I Out-Of-Service Well Renewal i Cross-Connection Repair <br /> W Pump Replacement i Pump Repair i Raise Well Casin <br /> wWELL CoNslTrucnoN TEST HOLE ONLY <br /> Drilling Method K Mud Rotary Air Rotary i Auger Cable Tool Push Point Other <br /> Proposed Well Depth 620 ft Excavation 8.75 in diameter �Open Bottom -1 Gravel Pack/Gravel Size in diameter <br /> Conductor Casing None in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter ..in Thickness/Gauge/ASTM Sched a Steel L plastic L Stainless Steel -i Other <br /> Grout Seal Depth_'Z _ft Neat Cement(941b begg�r5-10 gal water) Sand Cement 10. sack mixl7 al water <br /> A X Bentonite(20%solids) 'Mother Test hole will be zone sampled up until about loon using Bentonite c ipts.Cement last3o Gw--(0-�- 1 <br /> Grout Placement Method z Pumped n Free Fall -Other , Retardant/Accelerator(name) <br /> �j PEDESTAL Installed By I Driller - Pump Contractor [ Other <br /> a� fi�wlta>t1t S <br /> Concrete Pedestal -1Dimensions:Width ft Length ft Thick in IChristy Box - Stove Pipe <br /> MP TBA Submersible[ Turbine 1 Other HP Pump Set It Standing Water Level ft <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 1E <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGN aton Drilling Co Inc TITLE Authorized Agent DATE 8/26/2o15 'I'S <br /> LZ <br /> f 5 . T3 <br /> C�rr <br /> PER ! - 2Z5 <br /> ly. Eis l F.rmit may I <br /> :c <br /> J rH <br /> by Ln :rani r. :, t'I ..j <br /> -n <br /> DEPARTMENT USE ONLY <br /> LApplication Accepted By Date�l r l Area ° Employee ID# 0.-0aiv C1 <br /> Grout Inspection By Date ❑ SPEG Well Pemlt a� <br /> Pump Inspection By Date ❑ WAIVER Recelved %= '- <br /> 43 <br /> ��k G <br /> Soil Boringsppction�y Date Constructed eD Depth <br /> COMMENTS yL r vA•_I .l Q O�J <br /> PE Su Received heck#/ Amount Permit/ 0 <br /> Codes Into B as Remitted Service R est N Invoice N Wef5fo6g -LL) 9 1 1S 6 oV'QEHD 61064130/12WELL/PU <br />