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PHONE 551-5531 <br />PARCEL SIZEO,C LAND USE APPLICATION kI <br />HEPRY e CLO MARTIN c/o C LM CONSTRUCTION <br />MacARTHUR DR. APN 213 - z,7 <br />GEOGRAPHICAL INFORMATION: Coordinates X Range Section Township <br />WELL! PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3" FL- SrocscroiN CA 95202 - (209)468-3420 <br />NON-REFUNDABLE PERMIT CALL (209) 953-7697 OR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />6103 DELTA AVE.TRACY 6/s-3,7y. JOB ADDRESS <br />CROSS STREET <br />OWNER NAME <br />OWNER ADDRESS 2716 ODGED FOOT ('AY cm/s-I-ATE/zip TRACY, CA <br />CONTRACTOR HENNIKS CS. RILLING CO., INC. PHONE 545-1138 <br />CONTRACTOR ADDRESS 3525 PELWULE WE. CITY/STATE/ZIP MODESTO, CA 95356 <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br />LICENSE •'Sd C-57 0 C-6I 0-09 0 Other NUMBER 290'613 EXPIRATION DATE 5-31-08 SS3HOUV Al IS ERE/Q-02-00e <br />1127/2005 <br />WELL PUMP PERMIT <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Constructed Well Depth <br />COMMENTS <br />Date C> üt, Area Employee 109 5/0 i/5- rf <br />El SPECIAL Well Permit <br />o WAIVER Received <br />Date <br />Date <br />ft <br />„./ <br />PE <br />Codes <br />SC <br />Info <br />Received 1miog---5 <br />Cash <br />Amount <br />Remitted Date Permit/ <br />Service Request # invoice # Well ID# <br />14 31,10 I 2 0 A-- /---2, b/ 3,7 c- <br />AlrW, <br />INTENDED USE M Domestic/Private 0 Irrigation/Agricultural <br /> <br />0 Industrial 0 Water Quality Monitoring 0 Soil Sampling/Characterization <br />0 Public Water System <br />If different from Owner: Water Syszem Name Contact Name or Phone Number <br />TYPE l'_)L.%Vx1._c It New Well 0 Replacement Well 0 Well Alteration/Modification 0 Other <br />Monitoring Well(s) Pof wells 0 Soil Boring(s) of bonng 0 Geotechnical N of bonny 0 s <br />0 Out-Of-Service Well 0 Out-Of-Service Well Renewal 0 Cross-Connection Repair <br />0 New Pump 0 Pump Replacement 0 Pump Repair <br />WELL CONSTRUCTION <br />M Mud Rotary 04ir Rotary Drilling Method 0 Auger 0 Cable Toot 0 Push Point 0 Other <br />Depth 190 L•e Excavation 1 2 <br /> <br />in diameter 0 Open Bottom t Gravel Pack / Gravel Size in diameter Proposed Well <br />0 Conductor Casing in diameter / Conductor Casing Depth ft <br />Diameter 8 in TbeicriesstGauge/ASTM Sched 1 GOCL 0 Steel =Plastic 0 Stainless Steel 0 Other Well Casing <br />Depth 100 ) 1 DNeat Cement (94 th bag / 5-10 gal wetter) Grout Seal 0 Sand Cement sack mix 1 7 gal water <br />Eli Bentonite (20% ids) 0 Manufacturer Spec % solids 0 Specs on File 0 Specs Submitted % Name <br />Grout Placement Method tt Pumped 0 Free Fall 0 Other 0 Retardant / Accelerator (name) <br />Installed By 0 Drillerr Y.Pump Contractor PEDESTAL <br /> <br />0 Other <br />0 Concrete Pedestal Dimensions: Width in 0 Christy Bon 0 Stove Pipe ft Length ft Thick <br />PUMP 0 Submersible 0 Turbine 0 Other HP Pump Set ft 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 IS <br />LIRRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />SIGNED \AJ2J'YN CVNAMIer <br />MINIMUM 24 HOUR ADVANCE N TICE REQUIRED FOR INSPECTIONS <br />NasISCI D , E SUPERVISOR DATE 1 0-2-06 <br />r-^ <br />X.;) <br />z -9- 3 <br />5- <br />3- <br />4 <br />a <br />7is r-4 Er <br />Lan. 727 —)