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IN <br />WELL / PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3" FL- STOCKTON CA 95102 - (109) 468-3420 <br />CALL (ZUY) V -13-70Y7 FOR INSPECTIONS <br />DATE ISSUED <br />JOB ADDRESS 32705 Koster R d . /- C ry/ZlP Tracy <br />CROSS STREET s o u t h Of H W V 33 APN 2' ��' � �r� PARCEL SIZE '37 3LAND USE APPLICATION # <br />OWNER NAME John & Annamarie Lara PHONE 321-3541 <br />OWNER ADDRESS P.O. Box 795 CITY/STATP/ZIP Westley, CA 95387 <br />CONTRACTOR Hennings Bros. Drilling Co.,Inc. PHONE 545-1185 <br />CONTRACTOR ADDRESS 3525 P e l a n d a l e Ave. CITY/STATEPLIP Modesto, CA 95356 <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br />LICENSE lb C-57 C3 C-61 ❑ D-09 ❑ Other NUMBER 290813 EXPIRATION DATE 5/31/06 <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br />INTENDED USE Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br />❑ Public Water System <br />If difr-1 fmm 0"— .ar sym— sorsa . ame or ne Nub. <br />TYPEOF WORK 13New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # °fb—np ❑ Geotechnical x oflwnngs <br />❑ Out -Of --Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />❑ New Pump ❑ Pump Replacement ❑ Pump Repair <br />Drilling Method [I Mud Rotary [3 Air Rotary ❑ Auger ❑ Cable Too] ❑ Push Point ❑ Other <br />Proposed Well Depth 2 i Q- ft Excavation in diameter ❑ Open Bottom O(Gravel Pack / Gravel Size iJ O i" in diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter ._8 in ThickneWGauge/ASTM Schad 16 O C 1 ❑ Steel EXPlastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth 1 0 0 ft ❑ Neat Cement (94 Ib bag / 5-10 gal water) ❑ Sand Cement sack mar / 7 gal water / <br />EXBentonite (20% solids) ❑ Manufacturer Spec % solids % Name ❑ Specs on File ❑ Specs Submitted <br />Grout Placement Method IX Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller Pump Contractor ❑ Other <br />❑ Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑ Christy Boa ❑ Stove Pipe <br />PLiMP ❑ Submersible ❑ Turbine ❑ Other HP Pump Set ft Standing Water Level ft <br />1 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. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />INIMUM 24 UR AD NCE NOTICE REQUIRED FOR INSPECTIONS <br />SITITLE V . P . DATE 9/16/05 <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Constructed Well Depth <br />COMMENTS <br />EPARTMENT U E NLY <br />Data OS <br />Date <br />_ ft <br />1 <br />D <br />A <br />Ij <br />J <br />`1 <br />\tea' <br />Arra Employee ID# Z1000 <br />[3/PE IAL Well Permit <br />❑ WAIVER Received / <br />PE SC Received - <br />y <br />Codes Info B Cash <br />Amount <br />Date <br />Remitted <br />Permit/ # Well ID# <br />Service Request # <br />R41A ().s., <br />EH D 43-0:-006 WELL PUMP PERMIT <br />1/2712005 <br />