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?) WELL / PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3- FL- STOCKTON CA 95202 - (209) 466-3420 <br />NON-REFUNDABLE PERMIT CALL 209 953-7697 17OR I NSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br />JOB ADDRESS 6103 ';. DELTA AVE. CrryMp TRACY 175-3 o y <br />CROSS STREET I,IacARTHUR I)R. APN ,?13. -142 --LF PARCELSIZE .S:' LAND USE APPLICATION# <br />OWNER NAME HEPRY C", CLO i-!ARTIN C/C C CONSTRUCTION PHONE 551-5531 <br />OWNERADDRESS 2716 eiI°,,GED FOOT i:IAY CITY/STATPJZIP TRACY, CA <br />CONTRACTOR HENNIEGS 3ILLING CO.. Ii;C. PHONE 545-1135 <br />ADI <br />)p ADRESS 3525 PELA;iL�t1LE WE. CITY/STATEMP MOOESTO, CA �535t- <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS CITY/STATFJZIP <br />LICENSE Y C-57 ❑ Cfil ❑ D-09 ❑ Other NUMBER 290813 EXPIRATION DATE 5-31-08 <br />GEOGRAPHICAL INFORMATION! Coordinates X Y Township Range Section <br />INTENDED USE rA Domestic/Privatc ❑ Irrigation/Agricultutal ❑ industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br />❑ PublicWater S tem <br />If dderent r m — v-. oCo.-, oM or — N.mb. <br />TYPE OF WORK tail New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) a or boring¢ ❑ Geotechnical xotborir,g <br />❑ Out -Of -Service Well ❑ Out -0f -Service Well Renewal ❑ Cross -Connection Repair <br />❑ New Pump ❑ Pump Reolacetnent ❑ P=D Repair <br />Drilling Method b Mud Rotary it Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br />a <br />Proposed Well Depth 1 pG z1 Excavation 12 is diameter El Open Bottom It Gravel Pack /Gravel Size in diameter <br />O Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _' in kness/Gauge/ASTM Sched 1 GUCL ❑ Steel XtXPlastic ❑ Stainless Steel O Other <br />Grout Seal Depth 1 ) 13 Neat Cement (94 !h bag / 5-10 gal water) ❑ Sand Cement sack mix / 7 gal water <br />It Beaton c (20° o ids) ❑ Manufacntrer Spec % solids % Name ❑ Specs on File ❑ Specs Suhmitted <br />Grout Placement Method Ib Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelcmtor (name) <br />DE AL Installed By ❑ Driller iPump Contractor ❑ Other <br />❑ Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑ Christy Bos ❑ Stove Pipe <br />PUMP ❑ Submersible ❑ Turbine ❑ Other HP Pump Set ft Standing Waw Level ft <br />I HEREBY CERTIFY THAT 1 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 />_SUUNT AND ACTIVE WITH .THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />Application Acceptcd By Date 10 ZO !o <br />Grout Inspection By <br />Pump Inspection By Date <br />Constructed Well Depth ft <br />COMMENTS <br />Area Employee ID# <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />PE SC Received Amount Date Permit/ Invoice # Well ID# <br />Codes Info Cash Remitted Service R uest # <br />foo <br />EHD 43.0 406 WELL P1JW PERMIT <br />127/1005 <br />G <br />El <br />Tj <br />