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4'ELL / PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEP, ,MENT304 E WEBER A ,"°FL-ST WRP POM420 NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES I EAR f JOB ADDRESS 22803 East GaWne Road CITY/ZIP Stockton 95215 M CROSSSTREET Mobley_ Road APN � � U PARCEL SIZE U G OWNER NAME Lombardi , Frances Emma Trust et Al PHONE 948-1964 OWNER ADDRESS 16998 E Gawne Road CITY/STATE/ZIP Stockton, CA 95215 N CONTRACTOR Clark Well. , Inc. PHONE 209/462-7676 CONTRACTOR ADDRESS 2024 East Y Charter way Stockton, CA 95205 T CITYISTATEIZIP `J SUBCONTRACTOR Nine PHONE W SUBCONTRACTOR ADDRESS CITY/STATE/ZIP ` a M LICENSE �C-57 0C-61 IJ D-09 ❑Other NUMBER 371560 EXPIRATION DATE 04/04 GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range . Section UNTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization �] I ❑Public Water System r I If different from Owner: Water System Name ContiO Nimc or one um er + TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Ahcration/Modification ❑'rest Hoic ❑Other ❑Monitoring Well(s) number of wells ❑Soil Boring(s) numberofborings ❑Geotechnical number of horiags \ !� .I Well Destruction ❑Out-Of-Scrvicc Well ❑Otit-Of-Service Well Renewal ❑New Pump ❑Pump Replacement ❑Pump Repair ❑Cross Connection Repair 'J WELL CONSTRUCTION Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Too] ❑Push Point ❑Other Proposed Well Depth ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter ❑Conductor Casing in diameter / Conductor Casing Depth ft j Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other —S i Grout Seal Depth ft ❑Neat Cement(94 lb h0g/5-10gal water) ❑Sand Cement suck mix 17 gal water ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted — Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant 1 Accelerator(name) PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑Other ❑Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe Pump ❑Submersible ❑Turbine ❑Other HP Pump Set tl Standing Water Level 11 {i WELL DESTRUCTION IROpen Bottom ❑Gravel Pack ❑Uncased ❑Other Well Diameter 6 in Total Depth' 15 2 ' ft Depth to Water 101 ft ❑Casing to be Perforated from ft to ft Sealing Material ❑Neat Cement(941h hag/5-10gal water) ❑Sand Cement sack mix 17 gal water ❑Bentonite Pellets ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Placement Method J5 Pumped ❑Free Fall ❑Other ❑Complete with Mushroom Cap ft below grade ❑Complete to Existing Surface Pad 1 HEREBY C TIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN CO TY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT A ACTIVE YITH THE CA IFOINE RACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL f WORKERS CO ENSATI LA S. + MI 24 V REQUIRED FOR INSPECTIONS- PLEASE CALL (209)953-7697 SIGNED TITLE Sec-Tres DATE 4/8/03 I J A { AOti RCCIOk -- P 1.1G Al f 1, DEPARTMENT USE NLY Cl VA\j\ = - p''1 Application Accepted By � 1 Date "' Area + Employee ID# O U `� Grout Inspection By Datc 13 SPECIAL Well Permit PumpInspection By Date ��yy 11 WAIVER Received Destruction Inspection By Date �/3 Constructed Well Depth ft COMMENTS PE SC Received Check#I Amount Date Permit) Invoice# Well ID# Codes: Info B as Remitted Service Re uest# t EHD43-02-006 MASTER WATER WELL PERMIT 12/6/2002