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WELL / PUMP PERMIT � � SAN J61QUIN COUNTY ENVIRONMENTAL HEALTH ObW(RTMENT 304 E WEBE0%wk ape FL-STOCKTUN CA 95 A7�-, NON-REFUNDABLE PERMIT CALL 209)953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED y JOB ADDRESS 2327 East Mariposa Road R CIT Y/ZIP Stockton 95205 s CROSSSTREET Flemons Avenue APN�7 ��Z%0 —/O/ PARCELSIZE �•�� OWNER NAME Diesel Truck Service PHONE 465-1800 `? OWNER ADDRESS 2327 East Mariposa Road CITY/STATE/ZIP Stockton, CA 95205 CONTRACTOR Clark Well, inc. PHONE 209.462 .7676 CONTRACTOR ADDRESS 2024 East Charter Way CITY/STATE/ZIP Stockton, CA 95205 SUBCONTRACTOR None PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE C-57 4 C-61 0D•09 It Other A NUMBER 371560 EXPIRATION DATE 04/06 GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE f tDomestic/Private O Irrigation/Agricultural 0Industrial 0 Water Quality Monitoring 0 Soil Sampling/Characterization 0 Public Water System Ifdiffamnlfmn Owner: Water Synarn Name Contact Nam or Phone Number TYPE OF WORK IkNew Well 0 Replacement Well 0 Well Alteration/Modification 0 Test Hole 0 Other Q Monitoring Well(s) numberofwells 0 Soil Bofing(s) numberofburings 0 Geotechnical numterofb n.p 0 Well Destruction 0 Out-Of-Service Well 0 Out-Of-Service Well Renewal ©New Pump ❑Pump Replacement 0 Pump Repair 0 Cross-Connection Repair rT.T WELL CONSTRUCTION 1 Drilling Method AMud Rotary 0 Air Rotary 0 Auger 0 Cable Tool 0 Push Point ❑Other Proposed Well Depth 250 It Excavation 12 in diameter 0 Open Bottom 0 Gravel Pack/Gravel Size a 21 n in diameter 0 Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter 6 in Th' ness/Gauge/ASTM Sched SR 21 0 Steel Plastic 0 Stainless Steel 0 Other Grout Seal Depth 1 Neat Cement(94 Ib hag/5-J0 ga(water) It Sand Cement 10.3 sack mix/7 gal water 0 Bentonite(20%solids) ❑Manufacturer Spec%solids_% Name 0 Specs on File 0 Specs Submitted Grout Placement Method 3t Pumped 0 Free Fall 0 Other 0 Retardant/Accelerator(name) PEDESTAL Installed By I(Driller ❑Pump Contractor 0 Other M Concrete Pedestal Dimensions: Width 4 ft Length 6 ft Thick 4 in 0 Christy Box 0 Stove Pipe Pump %Submersible 0 Turbine 0 Other 8 HP 3 Pump Set 12 6 ft Standing Water Level 65 ft WELL DESTRUCTION 0 Open Bottom 0 Gravel Pack 0 Uncased 0 Other Well Diameter bin Total Depth 150+ ft Depth to Water 65�ft Casing to be Perforated from 6a" ft to 5/,r ft Sealing Material 0 Neat Cement(94/h hag/540 ga/water) 79 Sand Cement 10•3sack mix/7 gal water ❑Bentonite Pellets K ES 0 Bentonite(20%solids) 0 Manufacturer Spec%solids_% Name 0 Specs on File 0 Specs Submitted Placement Method Iq Pumped 0 Free Fall 0 Other 0 Complete with Mushroom Cap ft below grade 0 Complete to Existing Surface Pad I HEREBY RTIFY THA HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN C NTY ORDI A C S, STAT LAW AND RULES AND REGULATIONS. 1 ALSO CERTIPY THAT MY REQUIRED LICENSE IS CURRENT ACTIVE I HE A ORNI CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL i WORKERS PENSATI S. U ICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 SIGNED TITLE Sec-Tres DATE 9 Nov 05 t VIL. OU $ G E T - ,- - -- _ DEPARTME14- EUSN ��Application Accepted By ( Dal 'Yl�Area Employee ID# Grout Inspection B ❑ SPECIAL Well Permit Pump Inspection By Date / o ❑ WAIVER Received Destruction Inspection Date Constructed Well Depth ft COMMENTS p &cfe t.t)It 0- bmf D F'-- 1 nI +-L E.L U 0,VI On,1 r t t Y- — PE SC Received Check#/ Amount Permit/ Codes Info B - Cash Remitted Date erv,Jcc Reauest# Invoice# Well 1D# G C��k05 ti N d' 4KEn N Cs An J10- EHD 43.02-D06 I-��' 1'y �Zf+l. CG(7 e�7-X)6J;/ — r/�" 7/ MASTER WATER WELL PERMIT 12/6/2002 / - �OYL"1 rpi7i7Jr y Ti/JJ[-S