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WELL 1 PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3R9 FL-STOCKrON CA 95202-(209)460-3420 NON-REFUNDABLE PERM C11L1, 209 953-7697 FDR INSPE cTION5 EXPIRES l YEAR FROM DATE ISSUED W JOB ADDRESS 21801 Hig-hWay 120 CrrYlZip Escalon, 95320 - CROSS STREET Van Allen Rd. APN 205-250-02 PARRcELsizE 128 Acres Ovv"NAME Barrel Ten Quarter Circle Land Co. ._ PHONE 209-538-3131 owNExAnnREss 6342 Bystrum Rd. CTfY/STATE2IP Ceres, CA 95307 CONTRACTOR Kennedy/Jenks Consultants PHONE 415-243-2150 Q CDNrRAc ."URFss 622 Folsom St. CITYrsTATErzrPSan Francisco, CA 9410 _N SUBCONTRACTOR Spectrum Exploration, Inc. _ PHoNE209-465-8712 SUBCONIRACTORADDRESS 2365 Wigwam Dr. crrywAmup Stockton, CA 95205 p LICENSE NIP C-57 0 C-61 ❑D-D9 ❑Other NOMBER 5 12 2 6 8 EXHPATION DATE 4/p3 0/0 5 CEOGRAPHICALINFURMATION: Coordinates X Y Township,^ Rangef$y- Sectian36 1 WrENDED USE ❑DomestlCIPriVate ❑lrn8atiorVAgncultural ❑industrial X!r Water Quality Maritoring ❑Soil SamplirWCharacterization }1`tli ❑Public Water System Tfdiffvntf O%-w. wdasyaacNarne CeMaNamearPtLane a TYPEOFWORK C3 New Well ❑Replacement Well ❑Well AlterationlMAfication 13 Test Hole C3 Other I-ysl R1 P_t'Pr ❑Mordtoringwdi(s) mmnbaof—as ClSoil Boring(s) ra—herofbanns ❑Geotechnical nwabv ofbairnge ❑Well Destruction ❑Ord-Of-Service Well ❑Out-Of-Service Well Renewal ❑New Purnp ❑Pump Replacement ❑Purnp Repair 13 Cross-Connection Repair WELLCONSTRUCTON Drilling Method ❑Mud Rotary Cl Air Rotary XIXAuger ❑Cable Tool ❑Push point ❑Other Proposed Well Depth_ 42 It Excavation 6 t in diameter ❑Open Bottom xd Gravel Pack I Gravel Size_FLDujn diameter ❑Conductor Cuing�'�in diameter I Conductor Casing Depth ft Well Casing Diameter ±1.i� 'c"'Tfu k,,WCauge/AS&I Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other o Grout Seal Depth n/a ft Cl Neat Cement(94 fh bag/5-10 gal water) ❑Sand Cement sack min!7 gal water ❑Bentonite(20%solids) 0 Manufacturer Sped%solids % Name ❑Specs on Pile 13Specs Submitted Grout Placement Method ❑Pumped XX Free Fall r3 Othe ❑Retardant 1 Accelerator(name) PEDESTAL Installed By ❑Driller ❑Pamp Contractor )b Other n ❑Concrete Pedestal Dimensions: Width ft Length_ft Thick in ❑Christy Box ❑Stove Pipe PUMP ❑Submersible ❑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 from It to ft Sealing Material ❑Neat Cement(941b bogl J-10 gad water) ❑Sand Cement rack Tru 17 gal water ❑Bentordte Pellets M Bentonite(20%solids) ❑Manufacrater Spec%solids_% Name ❑Specs on File ❑Specs Submitted Placement Method ❑Pumped ❑Free Fall Q Other ❑Complete with Mushroom Cap ft below grade ❑Complete to Existing Sirfice Ped 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 BOARD AND THAT I AM IN COMPLIANCE WITH ALL ORKERS COMPEN TION LAWS. Dili\ ljM 2 H U NTAICE N0110E RE II[RED OR: EMONS r/ y SIGNED '/jti C�C.tlr 14�rE � DATE ®i 14 A fk IT -P II111 fit. I HE DLI H ARTMENT USE ONIft Application Accepted By Date Area t 1 _ Employee1Dt1 0/ Grout Inspection By Date 13 SPECIAL Well Permit !7 Pump Inspection By Date ❑ WAIVER Received Destmetionlnspec'm y Date Constructed Well Depth D COMMENTS PE V SC A otmt Received dr ate PermlU Imolce# Well 1119 Codes info Remitted Cash` B Service Re uest# �eoo a 04 0 EHD 43-02-006 y s3 /_fI $ {,w amit.doc 6!2012003 h�'�•+ W4 *Yll 133 -is30 - �