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`_'VELL PC-IP PERMIT }}// SAN JOAQUIN"COUNTY ENVIRONMENTAL HEALTH DEMENT 304 E WEBER A ""FL-STOCKTON CA 95202 - (209)46h=3420 NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES I'YEAR FROM DATE ISSUED 2.4500 S. 1�1acARTHUR UR. CITv1ZIPTRACY , CA R�76 JOB ADDRESS r� a CROSS STREET 14MILE S . O .t 4 F I !t,h S I-r. - APN 2 S Q 2 4 0-0 I ,- PARCEL SIZE OWNER NAME WESTERN REFRIGERATING AND COLD STORAGE PHONE 954 564- 1928 OWNER ADDRESS .2826 t �t1 E OAKLAND PARK B L V D. CITY/STATE/ZIP FORT LAUDERDALE FL 33306 CONTRACTOR N E!f'i'i'i I N G S BROS . DR ILLLNG C O. J�C INC . _ PHONE 545- 1185 CONTRACTOR ADDRESS_3525 P E L A N D A L E AVE . -MODE 5 T O ; CA 95356 SUBCONTRACTOR PHONE I SUBCONTRACTOR ADDRESS CITY/STATE/ZIP_ �...y� n w ■ � a■s 'yI ',yi'LICENSE UC-57 131C-61 ❑D-09 ❑Other .NUMBER 2 9 O 813 EXPIRATION DATE-5-711 -04 GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE ❑Domestic/PrNate- ❑Irrigation/Agricultuml YAndustrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization ❑Public Water Syystem If different from Owner: ater ystem ame ontac[Name or rnom NuMber TYPE OF WORK 0 NewWell ❑Replacement Well ❑Well AlterationlModi6cation ❑Test Hole ❑Other number of wells number of bi orn s ❑Monitoring We]](s} 11 Soil Boring(s) s ❑Geotechnical numberorbarings ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑New Pump Pum Replacement ❑Pump Repair ❑Cross-Connection Repair i WELL CONSTRUCTION Drilling Method Kl Mud Rotary El Air Rotary Q Auger ❑Cable Tool ❑Push Point ❑Other Proposed Well Depth 5,00 ft Excavation 12 Ii in diameter ❑Open Bottom Gravel Pack/Gravel Size in diameter ❑Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter 6 " in Thickness/Gauge/ASTM Sched 5D R 17 PVC ❑Steel IX Plastic ❑Stainless Steel ❑Other Grout Seal Depth 2 0 O 1 + ft ❑Neat Cement(94 lb hagl5-10gal water) IN$ai(d:Cl rnent sack mix 17 gal water ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Grout Placement Method t Pumped ❑Free Fall ©Other ❑Retardant/Accelerator(name) PEDESTAL Installed By ❑Driller IX Pump Contractor ❑Other 4 1 ❑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 11 WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other Well Diameter _in Total Depth R Depth to Water ft ❑Casing to.be Perforated from ft to ft Sealing Material ❑Neat Cement(94 lb hag 15-10 gal water) ❑Sand Cement sack mix/7 gal water IJ Bentonite Pellets ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ZI 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 JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I 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 WORKERS COMPENSATION LAWS. MINIMUM 24 HOUR ADVANCE NOTICE REQU RED FOR INSPECTIONS— PLEASE CALL(209)953-7697 SIGNED 4 c 9 i CI S N J A Fi .H RR M DEPART ENT�U' rNLY Uate i "—Applicat an•Accepted- Area / Employee 1D# V. r Grout Inspection By i•�l/L -Date !� ❑ SPECIAL Well Permit � w Pump inspection By Date ❑ WAIVER Received ,t Destruction Inspection By Date Constructed Well Depth ft COMMENTS O .J1 r .l 2-C PE SC Receivecr Amount Permit! Codes Info B Cash Remitted Date Service Request# Invoice# Well lD# ya�r r16 � a�aTo EHD 43-02-006 MASTER WATER WELL PERMIT 12/6/2002