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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL 611 DEPARTMENT 304 E WEBER AVE 3RD TOCKTON CA 95202- (209)468-3420 <br /> t t NON-REFUNDABLE PERMIT CAI..I, 209 953-7697 FOR INSI'ls(iTIONS EXP 1 YEAR FROM DATE ISSUED <br /> W <br /> JOB ADDRESS <br /> 21801 Highway 120 CITY/zip Escalon, 95320 <br /> � <br /> CROSSSTREETBenton Rd. Ap, 205-250-02 PARCEL SIZE 1Arrac <br /> OWNERNAME Barrel Ten Quarter Circle Land Co. _ _ PHONE 209-538-3131 <br /> OWNERADDREss 6342 Bystrum Rd. CITY/STATE/ZIP Ceres, CA 95307 <br /> CONTRACTOR Kennedy/Jenks Consultants PHUNE 415-243-2150 <br /> CONTRACTORADDRESs 622 Folsom St. CITY/STATE/ZIP San Francisco, CA 941317 <br /> SUBCONTRACTOR Spectrllm Exploration , Inc. PHONE 209-465-8712 <br /> SUBCONTRAcToR ADDRESS 2365 Wigwam Dr. CITY/STATE/ZIP Stockton, CA 95205 <br /> LICENSE ,ol C-57 ❑C-61 ❑D-09 ❑Other NUMBER 512 2 6 8 ..OND. 4/30/05 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range 08E Section -3-6 C>,a <br /> [INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural O Industrial 1 Water Quality Monitoring ❑Soil Sampling/Characterization Q <br /> ❑Public Water System \. <br /> Ifdifferentfrom Owner: Water System Name CwtactNarnemffi6neNmber <br /> TYPE OF WORK ) 1 New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other <br /> orutoringWeB(s) numberofwells ❑Soil Boring(s) numberofborings 0Geotechnical numberofborings <br /> ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal <br /> ❑New Pump ❑Pump Replacement ❑Pump Repair ❑Cross-Connection Repair <br /> W ELL CONSTRUCUON <br /> Drilling Method ❑Mud Rotary ❑Air Rotary 1 Auger ❑Cable Tool ❑Push Point ❑Other <br /> vv <br /> Proposed Well Depth 80 ft Excavation 1611 in diameter ❑Open Bottom 1�`Gravel Pack/Gravel Size #3 in diameter <br /> ❑Conductor Casing n/a in diameter / Conductor Casing Depth n/a ft (1 <br /> Well Casing Diameter 411 in Thickness//Gauge/ASTM Sched S C H 40 ❑Steelo XPlaStiC ❑Stainless Steel ❑Other <br /> Grout Seal Depth 165 ft X Neat Cement(94 1b bag/5-10 gal water) -3- 5 o nCk.rd sack min/7 gal water <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids_% Name ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method XPurnped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑Other <br /> ❑Concrete Pedestal Dimensions: Width_ft Length_it Thick in ❑Christy Box tove Pipe <br /> Pump ❑Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level ft <br /> WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other <br /> Well Diameter_in Total Depth ft Depth to Water ft ❑Casing to be Perforated from it to ft <br /> Sealing Material ❑Neat Cement(94 1h bag/5-10 gal water) ❑Sand Cement sack mix/7 gal water ❑Bentonite Pellets <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Placement Method ❑Pumped ❑Free Fall ❑Other <br /> ❑Complete with Mushroom Cap ft below grade ❑Complete to Existing Surface Pad <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I 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 /> bTINIM ,1124 HOURADVANCENOTICE RFEQIJRI D FOR INSPECTIONS <br /> SIGNED �Ys�v�V. � 'f✓Lici 4 TITLE DAT'_,'//'Z" <br /> �Zp03 <br /> VAN GOVNN <br /> �MENTP�164" <br /> EpART <br /> DEPARTMENUSEOApplication Accepted By Dated Area / Employee lD#Grout Inspection By ateQf ❑ SPECIAL Well Permit C <br /> Pump Inspection Date ❑ WAIVER Received <br /> Destruction InspectionBy Date Con ed W Depth ft'r <br /> COMMENTS <br /> 3- <br /> PE SC ount Check#/ Received Date Permit/ Invo # Well ID# <br /> Codes Info emitted B Service Re uest# <br /> Z2 pzD 00, (�D/ <br /> EHD 43-02-006 Master Water Well Pennit.doc <br /> 8/20!2003 <br />