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ELL / PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPAk.HENT 304 E WEBER AVE, 'FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT CALL.(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED LA JOB ADDRESS 20201A.Windwood Drive CITY/LIP Woodbridge 95258 y v Riverwood APN PARCEL SIZE J CROSS STREE l' — _�!!Jam'), " OWNERNAME Todd Nordman PHONE 481-7770 OWNER ADDRESS 2920 Alston Way CITY/STATE/"LIP Stockton, CA 95204 CONTRACTOR Clark Well, Inc. PHONE 209-462-7676 CONTRACTOR ADDRESS 2024 East Charter Way CIT,.'/STATE/LII' Stockton, CA 95205 SUBCONTRACTOR None PHONE: S U BCONTRACTO R A D D R ESS CITY/STAT E/ZI P LICENSE PkC-57 IkC-61 ❑D-09 ❑Other A NUMBER 371560 EXPIRATION DATE 04/08 GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE It Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization ❑Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK R%New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other ❑Monitoring Well(s) number of wells ❑Soil Boring(s) numberofborings 11 Geotechnical number of borings ND ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of=Service Well Renewal New Pump ❑Pump Replacement ❑Pump Repair ❑Cross-Connection Repair WELL CONSTRUCTION n Drilling Method Ik Mud Rotary`s ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other *� Proposed Well Depth 250 ft Excavation 12 in diameter ❑Open Bottom 13 Gravel Pack/Gravel Size 21 n diameter ❑Conductor Casing in diameter / Conductor Casing Depth tt Well Casing Diameter 6 in Thickness/Gauge/ASTM Sched CL200 ❑Steel ❑Plastic ❑Stainless Steel ❑Other Grout Seal Depth 150 ti ❑Neat Cement(94 lb hug/5-10 gal water) m Sand Cement •, :,r^c �,.,z;>suck mix/7 gal water ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Grout Placement Method 19 Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑Other ❑Concrete Pedestal Dimensions: Width ft Length tt Thick in ❑Christy Box ❑Stove Pipe PUMP IN Submersible ❑Turbine ❑Other HP 3 Pump Set 14 7 ft Standing Water Level WE:1.1.DE:STRUCI'ION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other -, Well Diameter in Total Depth ft Depth to Watej It ❑Casing to be Perforated from It to It Scaling Material ❑Neat Cement(94 lb bug/5-10 gal wider) ❑Sand Cement suck mix/7 gal water ❑Bentonite Pellets �— ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted rte`„ Placement Method ❑Pumped ❑Free Fall ❑Other p Ca ft below rade ❑Complete to Existing Surface Pad r � ❑Complete with Mushroomp g P g 1 HEREBY RTIFY THA I H E PREP A D THIS 'PPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN C TY ORDI A STATE WS, A RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS � ? CURRENT A ACTIVE I H HE C I O NIA TRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS ENS TI A M 2 N E REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 Sec-Tres 25 Mar 05 SIGNED v TrrLEVC A DA'Z'E JA VJ ti rI M ' y 1 E DEPARTMENT USE O� V Application Accepted By —7 Area Employee ID# Grout Inspection By ^i.�—' .r / Date ' '-• ❑ SPECIAL Well Permit �._. /cT ' ❑ WAIVER Received / Pump Inspecti� • �.� •�i/:, Date ./ Constructed Well Depth Date ft Destruction Inspection By _ COMMENTS y . t�� L, I- it •a PE SC Received (`Chec(k#/ Amount Dat Permit/ Invoice# Well ID# Codes Info BV ash Remitted Service Request# j ( _ z ? 3 S2o0So2 , r EHD 43-02-006 MASTER WATER WELL PERMIT 12/6/2002