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f A WELL/PUMP PERMIT SAN JOAQUiN COUNfY ENVIRONMENTALH EALTH DEPARTMENT 304E WEBER AVE 3a"FL-STOCKTON CA 95202-(209)469-3420 NON-REFUNDABLE PERMIT CALL 2119 953-7697 FOR INSPFC:T)ONS EXPIRES 1 YEAR FROM DATE ISSUED ` w JOaADDREss 218Q1 .--Hiqbway 120 crrymp Escalon, 9532.0 CRosssTREET Benton Rd. ,,P,,, 205-250-02 PARCEL SIZE 17R ArrAC OwNERNAME Barrel Ten Quarter Circle Land Co. PHONE .209-538-3131 owNERADDRrss 6342 Bystrum Rd. CrrrisTATTap Ceres, CA 95307 CONTRACTOR Kennedy/Jenks Consultants PrIONE 415-243-2150 CoNIRACTORADDREss 622 Folsom St. CTT/srATE1ZB, San Francisco, CA 94 7 suwomIzACroR Spectrum Exploration,ion, Inc- PHONE 209-465-8712 sU]iCDNrRACi'DRAD,,,, 2365 Wigwam Dr. CITYrSTAIFIZ, Stockton, CA 95205 c„ LICENSE XC-57 ❑C-61 ❑D-09 ❑Other NUMBER 512 2 6 8 EXP[RATrON DATE 4/30/05 `N GEocRAPRrcAL INFORMATION: Coordinates X Y ToWnship1s— Range 08E Seelloa. 36 O� INTENDED Use ❑Domestic/Private 0 Irrigation/Agricultural ❑lndustrW Water Quality Monitoring ❑Soil SamplinglCharacterization CN ❑Public Water Syys5tem _ If diff at rr Owner. ater st=n arse rsaact arae or me er TYPE OT WORKeW Well ❑Replacement Well 13 Well Alteration/Modification ❑Test Hale ❑Other onitoringWell(s) .—b—f—lb ❑SoilBoting(s) --banfbainp ❑Geotechnical maab—fb-W ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑New PurW ❑ Replacement ❑Pump Repair ❑Cross-Connection Repair WELL CONSTRUCTION Drilling Method ❑Mud Rotary ❑Air Retary I Auger ❑Cable Tool ❑Push Point ❑Other Proposed Well Depth 80 II ft Excavation �� in diameter 13 Open Bottom MVGmvel Pack/Gravel Size 3 in diameter ❑Conductor Casing n I a in diameter 1 Conductor Casing Depth n/a ft Well Casing Diameter-4,1 in Thickness/GaugOASCM Sched S- -C-EL—ALO ❑Steel XXlastLc C3Stainless Steel ❑Other Grout Seal Depth *65 ft X Neat Cement{941b bag 15-10 gal water) 3-5%d*9d9kent sackmlx77 gal water d Bentonite(20%solids) ❑Manufacturer Spec°/solids % Name ❑Specs on File C3 Specs Submitted Grout Placement Method XPurnped ❑Free Fall ❑Other ❑Retardant I Accelerator(name) PEDESTAL Iastalled By Q Driller ❑Pump Contractor ❑Other ❑Concrete Pedestal Dimensions: Width_ft Length_ft Thick in ❑Christy Ras tove Pipe PUMP ❑Submersible Cl Turbine ❑Other HP Pump Set ft Standing Water Level ft WELL.DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other Well Diameter_in Total Depth ft Depth to Water ft ❑Casing to be Perforated frorn ft to ft Sealing Material ❑Neat Cement(941b bag 15-10 gal water) 0 Sand Cement sack mix/7 gal water ❑Bentonite Pellets ❑Bentonite(20%solids) ❑Mamrfacturer Spec%solids %a Name 0 Specs on File ❑Specs Submitted Placement Method ❑Pumped ❑Free Fall ❑Other ❑Complete with Mushroom Cap ft below grade 17 Complete to Existing Surface Pad I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE HOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENS sATTIONNILAWS. Ir ,,Z �Gr/t: [ '11NIMUX 24 HOURADLVANC> NOTICE RL()UIRE33 FOR IN SPT,MONS SIGNED � 4'e'� f`�b :'Z 4 e c L r✓Vic,4 I• T. DATE l �2043 1, M��T a< DEPARTMENT USE,�Y 1 Application Accepted By Date Area Employee IDN Qr Grout inspection By to 0 SPECIAL Well Permit Pump Inspection Date 0 WAIVER Received Destruction Inspection By Date Can d W Depth 11f , COMMENTS if 7 PE SC oust Check#/ Recetved Date P--W Invo # Well IDN Codes Info mttted 8 Service Re uest# Z Z ll y b 04 EHD 43.02-006 Master water well Permit.doc