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WELL / PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DE ARTMENT 304 E WEBER A E 3'0 FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED • v� Joa ADDRESS 24500 S. M a c A R T H U R BLVDCITYIZIP TRACY � 7�O ,,,,� a CROSS STREET -Y4 MILE S. OF 11th St. APN 250-240-01 PARCEL SIZE�'" t LAND USE APPLICATION# OWNER NAME WESTERN REFREIGERTATING AND COLD STORAGE PHONE' ( 954 ) 564-,1.928 OWNER ADDRESS 2826 E. OAKLAND PARK BLVD. CITY/STATE/ZIP FORT _LAUDERDALE., FL CONTRACTOR HENNINGS BROS . DRILLING CO. , INC - PHONE 545- 1185 33306 CONTRAL"1'OR ADDRESS 3 52 5 - P E L A N D A L E AVE. ' CITY/STATE/ZIP M O D E S TOCA 95356 SUBCONTRACTOR W0� LJ41 PRONE 1(q2 3:1 / q0,3 SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE It G57. ❑C-61 ❑D-09 ❑Other NUMBER EXPIRATION DATE GEOGRAPHICAL INFORMATION: Coordinates X Y Township Ran a Se i to INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoringrttt in s a t I vn ❑Public Water System 1f different from Owner: Water System Name Contael Name or Phone-lTu-m-Ycr TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other ❑Monitoring Well(s) #of wells ❑Soil BoringN of borings N of borings s) ❑Geotechnical G ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑New Pump ❑Pump Replacement ❑Pump Repair ❑Cross-Connection Repair WELL CONSTRUCTION Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Toot ❑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 Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other Grout Seal Depth ft ❑Neat Cement.(94 lb hag/5-10 gal water) ❑Sand Cement sack mix l7 gal water ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/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 ft Standing Water Level ft WELL DESTRUCTION ❑Open Bottom Gravel Pack. ❑Uncased ❑Other Well Diameter bin Total Depth 126—ft Depth to Water ft ❑Casing to be Perforated from ft to ft Sealing Material ❑Neat Cement(94 lb hag/5-10 gal water) IX Sand Cement 10. 3 sack mix/7 gal water IJBentonite Pellets ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Placement Method Pumped ❑Free Fall ❑Other 12 G I LINE BLAST +Complete with Mushroom Cap 4 ft below grade ❑Complete to Existing Surface Pad 1 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 WORKERS COMPENSATION LAWS. MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS SIGNED ITL - SUPERVISOR DATE 5- 2 5—Q 4 i vl i4Y DEPARTMENT USE ONVY fLri7..-.._ .�._.A....._..�-- tee, Application Accepted By - Grout inspection By Date ❑ SPECIAL Well Permit qqq Pump Inspection By Date ❑ WAIVER Received I Destruction InspectiorkBy1� ✓ Date Constructed Well Depth ft /a-'30-- 2,34> COMMENTS �S c� cwt. 3ts8 �- E SC Received eck#/ Amount Date Permit/ ]Invoice# Well 10# Codes Info By Cash Remitted Service Request# -T7 -11-5:2 20 EHD43-02-006 MASTER WATER WELL PERMIT 12!2212003