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Ir ELL / PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPA .NT _ 304 E WEBER Avt TL-STOCKTON CA 95102 - (209)46$-3420 NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTION'S EXPIRES 1 YEAR FROM DAT u LD JOB ADDRESS 22803 East Gawne Road CITYIZIP Stocktonr l 9 CROSSSTREET Mobley Road APN_ + d QgQ V I PARC, iZE C I OWNER NAME Lombardi , Frances Emma Trust et Al PHONE 948-1964 y OWNERADDRESS 16998 East Gawne Road CITY/STATE/ZIP Stockton, CA 95215 CONTRACTOR Clark Well , Inc. PHONE 209/462-7676 CONTRACTOR ADDRESS 2024 East Charter Way CITY/STATE/LIP Stockton, CA 95205 {� i SUBCONTRACTOR None PHONE rQ SUBCONTRACTOR ADDRESS CITY/STATE/ZIP W iI LICENSE GatC-57 ❑C-61 ❑D-09 ❑Other NUMBER 371560 EXPIRATION DATE 04/04 GEOCRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization ❑Public Water System If different from Owner: ntcr ystem ame ontac[ ame or one um er TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other ❑Mpnitprin Wells number of wells number of borings number of borin s g ) ❑Soil Boring(s) ❑Geotechnical b J -M Well Destruction ❑Out-Of-Service Well 0out-01=Service Well Renewal Cp Q New Pump ❑Pump Replacement ❑Pump Repair ❑Cross-Connection Repair WELL CONSTRUCTION i Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other ,J.J Proposed Well Depth ft Excavation in diameter ❑Open Bottom ❑Gravel Pack I Gravel Size in diameter �^ ❑Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other Grout Seal Depth ft Cl Neat Cement(94 Ih hag/5-10 gal water) Cl Sand Cement suck mix 17 gal water .5—� ❑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 BV ❑Driller ❑Pump Contractor ❑Other i ❑Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe Pump ❑Submersible 11 Turbine ❑Other I-IP Pump Set ft Standing Water Level tt I WELL DESTRUCTION :�p Open Bottom ❑Gravel Pack ❑Uncased ❑Other 5 Well Diameter 6 in Total Depth 26 ft Depth to Water N A ft ❑Casing to be Perforated from fl to ft Sealing Material ❑Neat Cement(94 1b hag/5-10 gal water) Q Sand Cement sack mix I7 gal water ❑Bentonite Pellets ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Placement Method ❑Pumped ❑Free Fall ❑Other ❑Complete with Mushroom Cap ft below grade ❑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 JOAQUINqQUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT D ACTIVE TH THE CA JA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL WORKERS PENSAT N WS. NI 4 LA E TICE REQUIRED FOR INSPECTIONS- PLEASE CALL(209)453�1-7697 SIGNED TITLE Sec-Tres DATE 4/8/03 r L Fr it TO now I I i I I R 3 kgu P. l vlR rra —� �— — DEPARTMFNT"USE ONLY _ Application Accepted By—&g Date —:3 Area Employee lD# Grout Inspection By Date C, SPECIAL Well Permit C)O Pump Inspection By Date �{ ❑ WAIVER Received Destruction Inspection By Date-0, (DC7 Constructed Well Depth ft COMMENTS I PE SC Received Chec Amount Date Permit/ Invoice# Well ID4 Codes Info By Cash Remitted Service Request N d.._,... - MAy'llilt WAT41i WE?hL 111,NMIT 12/fif2tl4?