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R <br />173 WELL/PUMP PERMIT <br />S IN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 EAST MAIN STREET - STOCKTON CA 95202 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />Joe ADDRESS 3990 CALIFORNIA AVE. _ CITYiziip TRACY 95304 <br />CROSS STREET CANAL BLVD. APN 213-26018 PARCELSIZE 3' LAND USE APPLICATION 3r <br />OWNER NAME ALBERT EMHOFF c/o QUALITY SERV///ICES PONE 838-7842 <br />OWNER ADDRESS 27348 E. HWY 120 CITY/STATE/ZIP ESCALON, CA 953 20 <br />CONTRACTOR HENNINGS'BROS. DRILLING CO., INC. PHONE 545-1185 <br />CONTRACTOR ADDRESS 3525 PELANDALE AVE..` ClTYisTATEIZtP MODESTO,CA 95356 <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS CRY/STATEIZIP <br />LICENSE IX C-57 D C-61 0 Il . ❑ Other NUMBER 290813 EXPIRATION DATE5-31-10 <br />GEOGRAPHICAL INFORMATION: Coordinates Y Township_ Range Section <br />INTENDED USE :X Domestic /Private n Irrigatlon/Agricultural . -i Industrial n Water Quality Monitoring n Soil Samplingr.CharacterizaUon <br />C Public Water System <br />If differ -t from Ow rre ys em ame �unTa ame of ne um r <br />TYPE OF WORK Q. New Well r Replacement Wen U vveii imieranorurnoamcauon I I vurer <br />[IMonitoring Well(5) # of wells O Soil Boring(s) <br />of borings ng(s) u Geotechnical It of borings <br />D Out -Of -Service Well 71 Out -0f -Service Well Renewal C Cross -Connection Repair <br />D New Pump u Pump Replacement J Pump Repair <br />WELL CONSTRUCTION - <br />Drilling Method :-(Mud Rotary J Air Rotary C Auger n Cable Tool n Push Point L Other <br />Proposed Well Depth 200 ft Excavation 14 in diameter C Open Bottom IX Gravel Pack/Gravel Size in diameter <br />n Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter 8 in Thickness/GaugelASTM Sckied 160CL G Steel XI Plastic D Stainless Steel C Other <br />Grout Seal Depth 100 ft n Neat Cement (941D bag/5-10 gal water) J Sand Cement sackmixr7 gat water <br />E( Bentonite, (20% solids) n Other <br />Grout Placement Method L)(Pumped C Free Fall o Other O Retardant / Accelerator (name) \ ) <br />PEDESTAL Installed By G Driller Xi Pump Contractor C Other <br />❑ Concrete Pedestal Dimensions: Width ft Length It Thick in D Christy Box r Stove Pipe <br />PUMP j SubmersibleE Turbine J Other HP Pump Set ft Standing Water Level ft �?J <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 —JL <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 ADVAN -393 9E REQUIRED FOR INSPECTIONS <br />SIGNED t� �TyITLE SUPERVISOR DATE 10-9-08 l <br />I i <br />I <br />D P RTMENT U2E NLY <br />Application Accepted By Date O Area Employee ID# <br />Grout Inspect on By Date F SPECIAL Well Permit r <br />Pump Inspection By - Date C WAIVER Received <br />Soil Boring Ins'Rection qy Date trusted Well Depth ft <br />COMMENTS r,&J eeA ,m <br />PESC <br />Codes Info <br />Received <br />B <br />heck#/ <br />s <br />Amount Date <br />Remitted <br />Permit/ Invoice # Well ID# <br />Service Re uest # <br />I t O <br />NCr! <br />acv <br />3z 0 <br />5- 5— <br />EMD 43-06 - WELL PUMP PERMIT <br />9/INOI <br />