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1141) WELL 1 PUMP PEKM11 i SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEMENT 304 E WEBER A Nu FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT LL 209 953-7697 FOR INSPECTIONS I- ,,IRES I YEAR FROM DATE ISSUED rn JoBADDRM 11396 N. HIWAY 99 CITYIZIP LODI, CA. 95240 y CROSS STREET MORSE RD. APN a - PARCrL SIZE q V z OWNER NAME TNT TRUCKING PHONE (209) 931-6000 14 OWNERADDRESS 11396 N. }AWAY 99 . CITYISTATEIZIP LODI, CA. 95240 CONTRACTOR NOACK PHONE (209) 948-8817 CONTRACTOR ADDRESS 4500 E. FREMONT ST. CITYISTATEIZIP STOCKTON, CA. 95215 ., SUBCONTRACTOR PHONE ' SUBCONTRACTOR ADDRESS CITYISTATEIZIP LICENSE 13(C-57 ❑C-61 ❑D-09 ❑Other NUMBER 504513 EXPIRATION DATE 02103 C$OGItAPIIICAI.INrortMA'J'ION: Cnurdiullte,S X Y Townshlp Range Section INTENDED USE ❑Domesticli'rivale ❑Irrigntiun/Agricultural ❑Aidnstrial ❑Water Quality Monitoring ❑Soil Sampling/Charseterization ❑Public Water System Irdifferent from caner: WILICF SYsWnl Nnine Contact Norm or Phone NumWr TYPE or WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modificatidn ❑Test Hole ❑Other number of wells number of borings number of borings ❑Monitoring Well(s) 11 Soil Boring(s) 13 Geotechnical CKWell Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal r� ❑New Pump ❑Pump Replacement ❑Pum Re air ❑Cross-Connection Repair WELL CONSTRUCTION Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point O Other �.- I Proposed Well Depth 11 Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter ❑Conductor Casing in diameter / Conductor Casing Depth Well Casing Diarneler in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel 0 Other Grout Seal Depth 11 ❑Neat Cement(94 IL hug 15.10 gal wider) ❑Sand Cement suck mir 17 gal water i ❑Bentonite(20%solids) ❑Manulacturer Spcc%solids % Name ❑Specs on File ❑Specs Submitted Grout Placement Method '❑Pumped ❑Free Fall ❑Other 0 Retardant I Accelerator(name) PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑Other ❑Concrete Pedestal Dimensions: Width ti Length Il Thick in ❑Christy Box ❑Stove Pipe PUMP ❑Submersible ❑Turbine ❑Other HP–- Pump Set . ..11 Standing Water Level It Wba,l,DESTRUCTION ❑Open Ilot lom ❑(hovel Pick 13 Uncawd ❑Otho . Well Diameter_�in Total Depth 97 Il Depth to Water 70 ft ❑Casing to be Perlbrated from f1 to Il Sealink Material ❑Neat Cement(94 1h Lug/S-10gu!rrruca) IR Sand Cement sack,nix 17 gal water Cl Bentonite Pellets ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Placement Method ❑Pumped 54 Free Fall ❑Other ❑Complete with Mushroom Cap tt below grade ❑Complete to Existing Surface Pad 1 HEREBY CERTIFY THAT l 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 1S CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. 1NIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS { SIGNED f' « TITLE RETAIL SALES DATE 11-12-02 I ra 1 . f 1 C S y I i- O DEPARTMENT USE ONLY �RtSpkieution:Acc:ctitted-Ry-�(�i--,vel:J-`�J=(�c;�. Jatr••�1-1_=�1�~–,�=��Ar�a �- ' �mpioyee'1Dfi�`��''f'–!-�=°��""��T Grout Inspection By Date ❑ ' SPECIAL Well Permit I Pump Inspection By Date ❑ WAIVER Received Destruction Inspection H _ Date /��Zst�2� �JC�oynsstrueted Well Depth ft COMMENTS _� s''�c✓L1 �CfCr_.—-- – latl d Z PE SC Amount CheckA Received Dote Permit/ Invoice N Well ID# ('odes 111th Remilted ns r !3!' Service Request a �2. k EHD 43�2-006 MASTER WATER WELL PERMIT 51712002,`