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Il I k- <br /> f II WELL/PUMP PERMIT <br /> SAN JOAQIHN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3`°FL-STOCKTON CA 95202-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS - EXPIRES I YEAR FROM DATE ISSUED <br /> II � <br /> I JOBADDRESs 24707-S: BIRD RD. CITYIzIP TRACY 95304 a <br /> tv <br /> CROSSSTREET_ 11th. STREET APN 250-100-06 PARCEL SIZE R aC LAND USE APPLICATION# (t <br /> OWNER NAME DALEPETZ PRONE 836-0253 <br /> OWNERADDRESS P.O.'BOX 217 cITY/sTATFrztP TRACY, CA 95378 <br /> CONTRACTOR HENNINGS BROS. DRILLING CO.., INC. PHONE545-1185 --� <br /> ) <br /> CONTRACrixt ADDRESS 3525 PELANDA'LE<AVE., CITY/STATEPLIP MODESTO, CA 95356 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATEJZIP <br /> A I\ <br /> LICENSE &C-57 ❑C-6l ❑D-09 ❑Other NUMBER 29D813 EXPIRATION DATE 5-31-1 D V <br /> GEOGRAPHICAL INFORMATION: Coordinate& X Y Township_ Range Section <br /> INTENDED USE Domestic/Private ❑Trrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil SamplinglCharacterization <br /> ❑Public Water System <br /> Ifdiffirttit from Owner. W'etcr ystem Nems ontnce arae or one un r <br /> TYPE OF WORK 0 New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> ❑Monitoring WeII(s) #of wells ❑Soil Boring(s) a ofb.Ang, 0 Geotechnical #ofborings $. <br /> ❑Out-Of-Service Well ❑Out-Of--Service Well Renewal ❑Cross-Connection Repair <br /> ❑New Puttip ❑Pump Replacement ❑Pump Repair <br /> i WELL CONSTRUCTION - <br /> n <br /> Drilling Method M Mud Rota,{ry❑Air Rotary ❑Auger C3 Cable Tool ❑Push Point ❑Other <br /> Proposed WellDepth Excavation 14" in diameter E3 Open Bottom �l Gravel Pack/Gravel Sizein diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth fl <br /> � �.,/.� <br /> ,Well Casing Diameter _in icknessmauge/ASTM Schad 160CL ❑Steel MV']aslie ❑Stainless Steel ❑Other <br /> - Grout Seal Depth 100 t� ❑Neat Cement(94 Ib bag/5-10 gal water) ❑Sand Cement sack mix/7 gal water <br /> QI Bentonite(200A solids) ❑Manufacturer Spec%solids_% Name ❑Specs on File ❑Specs Submitted <br /> &.1 Placement Method 6 Pumped ❑Free Fall ❑Other ❑Retardant I Accelerator(name) <br /> DENTAL Installed By ❑Dr Iter ump Contractor O Other <br /> ❑Concrete Pedestal Dimensions:Width fl length ft Thick in ❑Christy Bax ❑Stove Pipe <br /> UMP (J Submersible ❑Turbine ❑Other HP Pump Set R Standing Water Level ft <br /> I HERBY 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. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> ( I, <br /> MINIMUM 24 HOUR . DVANCE O E REQUIRED FOR INSPECTIONS <br /> ` SIGNED i>�'r, ' TITLE SUPERVISOR DATE 7`2`09 _ <br /> 1 <br /> +jt <br /> 1 <br /> i <br /> t <br /> I • t <br /> � o <br /> I <br /> IN '01 INTY <br /> c Ot <br /> ENT <br /> kiI <br /> � DEPARTMENT U E ONLY O <br /> Application Acccptcd 13 t s T).w . O Area Cmployee[D# O /aa <br /> Grout Inspection By ate ❑ SPECIAL Well Permit I 1 <br /> Pump Inspection Bye Date ❑ WAIVER Received <br /> ConstructedptIs ft <br /> CO E TS��o�-`U't ["}'-�'�_ - OD 'YD <br /> PE SC Received Chec Amount Date Permit! lnvaice# We111D# <br /> Codes Info By Cash Remitted Service Re nest# <br /> 2��2� ted 0 � ¢ <br /> li <br /> t - EHD 43-02-006 it WELLPIJMPPERMrr' ' <br /> 1 YL720d5 m „ <br />