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(/;DD arra 527W WELL/PUMP PERMIT ,'MENT 304 E WEBER A1. -,"o FL-STOCKTON CA 95202 - (209)468-3420 SAN JCAQUIN COUNTY ENVIRONMENTAL HEALTH DEI NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED i JOB ADDRESS 24500 S. Ma('ARIHUR RI VD.- CITY/ZIP TRAPy je CROSS STREET fI4 P1IL6 S. OF 11th St. APN 2 5 0-2 4 0-01 PARCEL SIZE u'VC1 LAND USE APPLICATION# A OWNERNAME WESTERN REFREIGERTATING AND COLD STORAGE PHONE _(954) 56A-1928 OWNERADDRESS 2826 E. OAKLAND PARK BLVD. CITY/STATEIZIP FORT LAUDERDALE FL CONTRACTOR HENNINGS BROS QR111 INC CO INC 33306 p l2gtl, r PHONE_S 5-1 18.5 CONTRACT OR ADDRESS PELA—NDALE oAVE. SUBCONTRACTOR (JJ-- W-V CITY/STATE/ZIP MODEST�O, CA95356 PHONE/7I-) k3:2--?00 -3 SUBCONTRACTOR ADDRESS CITY/STATEIZIPC(,- -X,-L _ C,09 I b LICENSE 0 C-57 ❑C-61 ❑D-09 ❑Other NUMBER 2 9 EXPIRATION DATE GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Chamctenzation ❑Public Water System If differ—from Owner. -ter yrtem ame onizet ame or one TYPE OF WORK ❑New Well ❑Replacement Well ❑ ell Alteration/Modification ElTest'ITnle ❑Other ❑Monitoring Well(s) #of wells US.oil Boring(s) P it of borings ❑Geotechnical 4 of borings G ❑Well Destruction ❑Out-Of-Scrvice Well ❑Out-Of-Soviet Well Renewal ❑New Pump ❑Pump Replacement ❑Pump Repair - ❑Cross-Connection Repair WELL CONSTRUCTION Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other Proposed Well Depth It Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter ❑Conductor Casing in diameter / Conductor Casing Depth fl Well Casing Diameter_in Thickness/Gauge/ASTM Sched ❑Stec] ❑Plastic ❑Stainless Steel ❑Other Grout Seal Depth ti ❑Neal Cement(94 lb hug/5-10 gal water) ❑Sand Cement .tack mix/7 gal water ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted ,rout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) 'EDESTAL Installed By ❑Driller ❑Pump Contractor ❑Other ❑Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe 'UMP ❑Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level ft YELL DESTRUCTION ❑Open Bottom P(1 Gravel Pack ❑Uncased ❑Other Well Diameter_bin Total Depth 12 6 ft Depth to Water fl ❑Casing to be Perforated from ft to fl � Sealing Material ❑Neat Cement(94/b bag/5-10gal water) 19 Sand Cement 10.3 sack mix/7 gal water ❑Bentonite Pellets \ ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Placement Method Pumped ❑Free Fall ❑Other 12 0 1 L I N E BLAST dComplete with Mushroom Cap 4 fl below grade ❑Complete to Existing Surface Pad HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN OAQUIN COUNTY ORDINANCES, STATE LAWS,AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS 'URRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL YORKERS COMPENSATION LAWS. - ICNED MINIMUM 24HOUR AD� SUPERUISORATE5-25-04 VANC'ENOTi.eCEREQUIRED RINSPECTIOND llnn ��J J VI NT DEPARTMENT USE ON Y Application Accepted By s �J ..to �i 0 Arca Employee ID#�� Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By ,/ f� Date ❑ WAIVER Received / Destruction I �tion�BJ y f�l/( //�✓ Date Constructed Well Depth ft �0 $t 3MMENTS 0 5 8 /.�.Jf 57,1 ?-6 L"6 6 Loos C,4V— 3110 5 O ? +) E SC Received eck#/ Amount Date Permit/ Invoice# Well ID# Codes Info B Cash Remitted Service Request# 3�3 7y1 o r�9 5 2a 0 14,-)- 343-02-006 MASTER WATER WEIR,PERMIT !72003