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WELL v P PERMT <br /> SAN JOAQUt? rgTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3"FL-STOCKTON CA 95202 - (209)46h=3420 <br /> NON-REPUNDABLEIPERMIT CALL 209 9537697 FOR IN ECTIOTIS ZXP11tESTYZAR FROM DATE ISSUED <br /> M�cA <br /> 2450-0 S. . �RT�WU•R . <br /> JOB ADDRESS DRCTCY/7.1P TRACY , C A qs376 <br /> • e <br /> CROSS STREET A MILE S. OE 111h ST, APN. S U-2 4 0-0 1 PARCEL SIZE <br /> OVMERNAME WESTERNREFRIGERATING 'AND COLD STORAGE PHONE ( 254) 56 4-1928 <br /> OWNER ADDRESS -28iLE, DAUM PARK BLVD CrrymATE/T.IP-FORT LAUDFRDALEe- FL 33306 <br /> CONTRACTOR N E NDN I NGS BROS. DRI L I.N G CQ. ' INC• PHONE 545-1185 <br /> CONTRACTOR ADDRESS - 3-525 R E L AN D AL E -AVE. cmvisrAnmp M O D E S T O. CA 95356 <br /> SUNCOMMACTOR PHONE <br /> SUaCONTMCToRADDRESS_ CrrV/STATE/ZsIP <br /> LICENSE XYr,57 Qt;-6.1 0 D-09 0 Other Nmm .. ExPiRAT10N DATE <br /> GEOGRAPHICAL INFORbtA'nON: . Coordinates X Y Township Range ' Section <br /> INTENDED USE 13 Domestic/P vste- 0Irri;tionlAldiultural ndustrisl CYWaterQuality Monitoring D Soil SamplingtCharacterization <br /> 0 Public Water System <br /> V diRereat from &ter System Nafm Contact Nam m FNM Numew <br /> TYPE OF WORK 0 New Well D Replacement Well 0,Well AlterationlModification 'Cl Test Hole 0 Other <br /> C Monitoring Well(s) numbarofwells p Soil Boring(s) number6f6orintp 0 Geotechnical auoAmOfbeua6K <br /> 0 Well Destruction 0 Out-Of--Service Well 0 Out-Or--Service Well Renewal <br /> 13 New Pum 0 Pume Replacement 13 Purop Rvair 0 Cross-Connection.R it <br /> WELL CONSTRUCTION <br /> Drilling Method P Mud Rotary Cl Air Rotary 0 Auger 0 Cable Tool 0 Push Point 0 Other <br /> Proposed Well Depth 5-0 0 R Bxcavation___---12°_ in diameter O'Opcn Bottom 10 Gravel Pack I Grovel Size in diameter <br /> c <br /> 0 Conductor Casing_in diameter / Conductor Casing Depth A c <br /> Well Cuing Diameter-"-in Thickness/GaugeJASTM Sched S D R 1 7 Ove 0 steel ix Plastic P 0 Stainless Steel 0 Other <br /> Grout Seal Depth 200 1 + ft 0 Neat Cement(94!b hag/S-iF at water) IN,$'K.l:CAment 10-1 .sack mix/7 gal water <br /> 0 Bentonite(206A solids) 0 Manufacturer Spec%solids %. Name O Specs on File O Specs Submitted <br /> Grout Placement Method 0 Pumped 0 Free Fall 0 Other 0 Retardant/Accelerator(name) <br /> PEDESTAL Installed By C3 Driller EX Pump Contractor D Other. <br /> 0 Concrete Pedestal Dimensions: Width' ft Length ft Thick in 0 Christy Box 0 Stove Pipe <br /> PUMP 0 Submersible 0 Turbine O Other .. : HP Pump-stt ft Standing Water Level ft <br /> WELL DESTRUCTION 0 Open Bottom 0 Gravel Pack 0 Uncalled 0 Other <br /> Well Diameter in Total Depth ft Depth to Water ft 0 Casing lobe Perforated from ft to ft <br /> Sealing Material 0 Neat Cement(91 lb bag/S-10gal warer) 0 Sand Cement sack mux/7 gal water 0 Bentonite Pellets <br /> 0 Bentonite(20%solids)- O.Maeullicttirer Spec%-solitis % Name � __ _ 0 Specs on File D Specs Submitted <br /> Placement Method O Pumped 0 Free Fall 0 Other <br /> O Complete with Mushroom Cap ft below rade 0 Complete to Existing Surface Pad <br /> I HERESY CERTIFY THAT i HAVE PREPARED THIS APPLICATION ANO-THAT THE WORK WILL. BE WNE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 24 HOUR ADVANCE NOTICE RI; LRED FOR INSPECTIONS—PLEASE CALL(209)953-7697 <br /> SIGNEDwul i;r <br /> r <br /> CL Zj'ft U1 <br /> C <br />