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Dec 05 14 04:24p Ken Goss Wells & Pumps <br />20974585RA p.3 <br />WELUPUMP PERMIT <br />SAN JOADL[N CouNTY ENUROMENTAL HfALTH DEPARTMOJT 1868 EAST HAT3T0N AVENU2- STCCKTON CA 95205 - (209)463-U20 <br />NON-REFUNDABLE PEFI]MOT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br />CROs STREET - APN ' L-149 ' ARCELS2ELAN0 USEAPPUCATIOb f <br />OWNER NA ME PHONE <br />OWNERAODRESS CTTYISTATEMP <br />CONTRACTOR 1� PHCNE <br />CONTRACTORADOREss Crn15TATFJLP_r-�z <br />SUBCONTRACTOR PHONE <br />ADDRESS <br />CrTYISTATEMP <br />n C-61 71 D-09 Other NUNeER EXPIRATION <br />_- e- v Y 7owrship _— Ran to Secti— <br />vevc.xs.r =N: ............-.._._ <br />INTENDED USE C DomestlarPrrvate mgaLONAatieultural 0 Industrial ❑ Water Quality Monitoring So@ SamprtngXharac:edzAOn <br />I_ Public" later System ema ar Plwaa�u er <br />V'GN-A from Omer= v em - <br />TYPF O.WO Well 7 Replacement uveil L Well .vneracOWN10c Tircarl u vu- <br />r- MOnloring Well(s) #o`vrells r SaiBoring(s) ts of Eai ngs rl Geolerhnical^_ 0&b.0 -g-, <br />i, Out -0l -Service Well C Ou"Sendre Well Renewal 0 Cross -Connection Repair <br />Drilling Ntethod D Mud Rota y _• Air Rotary Auger�ableTool 0 Push Poeni C Other <br />Proposed Well Deptb2 4 Excavation I Cr/ in dlameler _P<p-a Bottom l Gravel PacluG.vel SUP in diameter <br />L Conductor Casing in diameter I Conductor Casing Depth , > fl <br />Well Casing Wameter // lin Thkhness/GaugeIASTM Schad . � Steel n Ptasvc n Staintss Steel Other <br />Grout Seal Depth Q_fi 0 Neat Cement (94 Ib hagr5-10 ga) vrafeO ` and Cement sack rnixR gal water <br />C Bentonite (20% solids) 5 Other <br />Grout PlacementMethod urnped 7 Free Fall D Other = Retardant/Accelerator(name)__ <br />PEDESTAL Installed By niUer n Pump Contractor n Othe- <br />r • Concrete Pedes - 1 nDimanslors:Width `�_ft Length kThirY, in 7 Christy Box : Stove Pipe <br />PuwP uGlnersihfert Turbine 0 Other HP Pump Set/,6e:7 ' 1t StaniMng Water Level <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 REGULATION& 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTWE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />LMIN! UM 2/4 � YR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209 953-7697 <br />cis �I, INCL—�'"--. �.-- _ 71Ti.E - DATE <br />DEPARTMENT USE ONLY 1 l <br />App", on Accepted B Date \Z , Area "< tI G Employee IDP <br />Grout Inspection - Date ❑ SPECT WBII Parrott <br />Pump Inspection By 1 Date a WAIVER Received <br />S6, Boring lrLSpection By pate Conslnrcted Well Depth it <br />C010MENTS <br />mq)-�7 <br />DEC 10 201 <br />EyoE4L� pe �N�Y <br />C.— <br />PE SC Received <br />Ch --kV Amount PerDate <br />Dam <br />Invoiced Welll� <br />Codes Info B <br />Cash Remitted Service Requostil <br />_ <br />Oo'W" <br />y <br />70610- 'ai5 <br />0 3 1 <br />Received lyime Dec, 5. 2014 3,47FM No, 7664 <br />