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WELL/PUMP PERMIT <br /> • SAN JOAQUIN COUNTY ENVIRONMENTALH DEPARTMENT 304 E WEBER AVE 90 FL-STOCKTON CA 95202- (209)468-3420 <br /> NON-REFUNDABLE PER CALL, 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> N <br /> JOBADDRESS 21801 Highway 120 <br /> CITY/ZIP Escalon. 95320 9 <br /> 128 Ad <br /> CROSS STREET Van Allen Rd• APN 205-250-02 PARCEL SIZE Acres <br /> OWNER NAME Barrel Ten Quarter Circle Land Co. PHONE 209-538-3131 <br /> OWNER ADDRESS 6342 Bystrum Rd. CITY/STATE/ZIP Ceres, CA 95307 <br /> CoNTRAcrOR Kennedy/Jenks Consultants PHONE 415-243-2150 4 <br /> CONTRACTOR ADDRESS 622 Folsom St. CITY/STATE/ZIP San Francisco, CA 9410 <br /> SUBCONTRACTOR Spectrum Exploration, Inc. PHONE209-465-8712 <br /> SUBCONTRACTOR ADDRESS 2365 Wigwam Dr. CrrY/STATE/zip Stockton CA 95205 p <br /> LICENSE C-57 ❑C-61 ❑D-09 ❑Other NUMBER 512 2 6 8 EXPIRATION DATE 4/3 0/0 5 <br /> GEOGRAPHICALINFORMATION: Coordinates X Y TownshIII Range Section_ <br /> DVTENDED USE ❑Domestic/Private Cl Irrigation/Agricultural ❑Industrial X)[3 Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> V diVicerd from Owner: Water Syslan Narrc Contact Name or aneNian v <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other L 3j S l TTI P t P Y <br /> number of wells [3camber of borings Geotechnical <br /> number of borings <br /> ❑Monitoring Well(,) Soil Borings) <br /> ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal <br /> ❑New Pump ❑Pum Re lacement ❑Punm Re air ❑Cross-Connection Repair <br /> W ELL CONSTRUCTION <br /> Drilling Method CIMud Rotary [3 Air Rotary XXAuger ❑Cable Tool E3Push Point [3 other <br /> Proposed Well Depth_E?Sft Excavation 16.1 in diameter C3Open Bottom X0 Gravel Pack/Gravel Size F 1-0,U-in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter ±1.i5 f Thic7 kness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth n/a ft ❑Neat Cement(94 lb bag/5-10 gal water) ❑Sand Cement sack mix/7 gal water <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method ❑Pumped XX Free Fall ❑OthelBP n Y 0111 l t e ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor YO Other n <br /> ❑Concrete Pedestal Dimensions: Width ft Length_ft Thick in ❑Christy Box ❑Stove 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 ft to ft <br /> Sealing Material ❑Neat Cement(94 lb bag/5-10 gal water) ❑Sand Cement sack mix l 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 /> COMPEN TION LAWS. <br /> AORKERS H L b12 H I�UI f� '0'^OOLECF.REQI7RED�'OR SPECTIONS <br /> DATE 6 O 3 <br /> SIGNED L/.� ,7 <br /> Ism wo <br /> IT 49 AT <br /> ARTMENT USE ON c� f <br /> Application Accepted By Date / C Area_ a f L Employee ID# e7/ <br /> Grout Inspection By Date [3 SPECIAL Well Permit / <br /> h( <br /> Pump Inspection By <br /> Date ❑ WAIVER Received <br /> Destruction Inspec on y Date Constructed Well Depth it <br /> COMMENTS <br /> PE SC A outd Old ec Received PermM/ Invoice# We11ID# <br /> B ate Service Re ue,t# <br /> Codes Into Remitted <br /> 02EHD 43-02-006 / 0,f �O�W ennit.doc <br /> 8/20/2003 <br />