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WELL:-''i MP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3a"FL-STOCKTON CA 952P 1209)466M- 20 NON-REFUNDABLE PERMIT CALL(209)`la_I'.�-7697 FOR INsrecTlo�s EXPIRES 1YEAR FROM- ISSUED CITY/ZIP s JOB ADDRESS 24500 S. MacARTHUR DR. TRACY CA gS376 Y CROSS STREET % MILE S. OF 11th ST. APN_ 250-240-01 PARCEL SIZE -o_ p OWNERNAME WESTERN REFRIGERATING AND COLD STORAGE PHONE(954) 564-1928 H OWNERADDRESS .2826 E. OAKLAND PARK. BLVD, CITY/STATE/ZIP FORT LAUDFRDALE, FL 33306 CONTRACTOR HENNINGS BROS. DRILLING CO.;: INC. PHONE 545-1185 CONTRACTOR ADDRESS 3525 P E L A N D A L E AVE. CITY/STATEIZIP MODEST 0. CA 95356 SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE I(C-57 ❑C-61 ❑D-09 ❑Other NUMBER 290813 EXPIRATION DATE 5-31-04 GEOGRAPHICAL INFORMATION: Coordinates X V Township Range Section INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural Wndustrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization ❑Public Water System a Ifdiffemm from Owner ater ystem amn-a- me or one um r TYPE OF WORK CO New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other ❑Monitoring Well(s) numberofwells ❑Soil Boring(s) number of borings numberofborings ❑Geotechnical ❑Well Destruction ❑Out-Of--Service Well ❑Out-Of-Service Well Renewal ❑New pump ❑Pump Replacement ❑Pump Repair ❑Cross-Connection Repair WELL CONSTRUCTION Drilling Method Cp Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other Proposed Well Depth 500 ft Excavation 12 r1 in diameter ❑Open Bottom 01 Gravel Pack/Gravel Size in diameter ❑Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter 6 Ir in Thickness/Gauge/ASTM Sched SDR 1 7 QVC ❑steel [J(Plastic ❑Stainless Steel ❑Other Grout Seal Depth 2001+ ft ❑Neat Cement(94 1b hag/5-10 gal water) IA$at(d gment 10-�j .rack mix/7 gal water • ❑Bentonite(20%solids) ❑Manufacturer Spec%solids_% Name ' ❑Specs on File ❑Specs Submitted Grout Placement Method 01 Pumped ❑Free Fall 13Other O Retardant/Accelerator(name) PEDESTAL Installed By ❑Driller IX Pump Contractor ❑Other ❑Concrete Pedestal Dimensions: Width' It Length ft Thick in ❑Christy Box ❑Stove Pipe PUMP EI Submersible ❑Turbine ❑Other HP Pump Set R Standing Water Level ft WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other Well Diameter in Total Depth ft Depth to Water ft ❑Casing to be Perforated from ft to ft Sealing Material ❑Neat Cement(94 lb bag/S-10ga1 water) ❑Sand Cement sack mix/7 gal water ❑Bentonite Pellets ❑Bentonite(20e/solids) ❑Manufacturer Spec%solids_% Name ❑Specs on File ❑Specs Submitted Placement Method ❑Pumped ❑Free Fall ❑Other ❑Complete with Mushroom Cap 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. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MINIMUM 24 HOUR ADVANCE NOTICE RE Ul RED FOR INSPECTIONS-PLEASE CALL(209)953-7697 SIGNED __-_ _ _ I— C 11111 LE r 9 CI c SN J AUl H EAR M L DEPARTTMENTrA NLY /� Application Accepted By_ Zai �✓>'/`� pate d Area 9 Employee ID# Grout Inspection By _ �h� DateG� 11SPECIAL Well Permit Pump Inspection Bye! Date ❑ WAIVER Received Destruction Inspection By_ Date Constructed Well Depth ft COMMENTS r PE SC Receive hec Amount Permit/ Codes Info B Cash Remitted Date Service Re ucst# Invoice# Well ID# yaTra5a EHD 43-02-006 12/6/2002 MASTER WATER WELL PERMIT