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Dec 05 14 04:24p <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENIARONN ENTAL HEALTH DEPARTWOJT 1868 EAST HAZFLTaN AVENUE - STOCIITON CA 95205 - (Zug)46a-U20 <br />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES i YEAR FROM DATE ISSUED { <br />JOB ADDRESSI,-+—) ^ D <br />b <br />CROSS STREET AP N —�_�ApGEL$¢E �L D lJNO USE APPLICA_TION o <br />�� s <br />^ / m <br />y J <br />Ken Gross Wells & Pumps <br />20974585RA p.3 <br />OWNER NARE <br />SC Received <br />CheekW <br />PHONE _. <br />WellID9 <br />Codes <br />OWNER AOORESS �.. <br />Cash <br />CRYISTATEI2tP <br />F+ <br />i <br />3�t I S <br />PHONE <br />CONTRACTOR <br />Ar <br />z� <br />'A,Cr <br />1STATEm" <br />CONTRACTOR ADDRESS <br />SUBCONTRACTOR <br />PHONE <br />_ _ <br />SUBCONTRACTDR ADDRESS <br />CrTYISTATEf7j <br />LICENSE rt G61 <br />:i D-09 Cther <br />NUMBER <br />Ex PIRATIDNDATE. <br />r QTeinM— X <br />Y Township <br />— Ranga Semon <br />NTE14DED USEL' •C DOrneslfUPnNAg <br />vate mgatiaticultural D Industrial C Water Quality EAoruloung J m <br />SCO Sapll,"W Cha,raceraaliOn <br />1- Pubric Water System va�B or no <br />Ir&JN.vM tmm Owra r u em rno <br />TYPE O�Wo Wen 7 ReplaoementWell C VJellAteraConrrtoOlr eRan vela <br />0.1 pa{ G� A of bodafls <br />r NonToringVJell(s) �oFwclls f SaiIBOling(s) n Geolerlutigl <br />L Out -OI -Service Well C Out-0iSer it e Well Renewal ❑ Cros,Connedion Repair <br />�a 4", P�rmn � 'Umo 1'ieaacement C Purnp Repair C Rase Wcl Canna <br />Drilling Method i_ N.Ud Rota i J Air Rotary L PLgert;;?<able Tocl ❑ Push Pdnl C Other <br />Proposed Well Cepthfl Expration _ I ITi m dErr erer sn Bottoml Gravel Padu'G:avel SfzE in diameler <br />L COrdJ=.r Casing_ Z in diameler 1 Conductor Casing Death- <br />Well Casing DiameterLl]in ThiU(nesSl Uge/ASTM-'Je Steel n Plastic i ShintessSteel . Other <br />Grout Seal DepUl // ``' �`fi O "teat Cement (94 !b haW5-10 gal water) �§ `and Cement sack twff gal voter <br />C Bentcnite (20% scuds) L ON <br />Grout Placement MerTrod - urnped J Fns Fall C Other = Retardant /Accelerator (name) <br />PEDESTAL Installed By d2er Ti Pranp Contractor n Othe- <br />r ConcretoPedes I rTDimens]ons:Wdlh ft Length ftThick. in , ChrishBox ' Stnve Pipe <br />PuaP 1jDcrersitleOTurbine 00ther HP Pump Set OLCft 5'andSingWater Le,el�fl <br />I HFRE13Y CERTIFY THAT I HAVE PREPARED THIS APPIJCATION AND THAT THE WORK WILL SE DONE IN ACCORDANCE WITH SAN <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RUMS AND REGULATIONS. I ALSO CER71FY THAT MY RECLURED LICENSE IS <br />CURRENT AND ACTWE WrrH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />MINI UM 24 y)R ADVANCE NOTICE REQUIRED FOR <br />(INSPECTIONS - PLEASE CALL (209 953-7697 <br />cis -u n k -- - -_ 7h'. `• _ DA1:F� <br />'SFr YW�� T <br />D <br />EyRO,CO <br />�1,�OF' ��(� <br />DEPAWfMENT USE ONLY �,(�r <br />Appl' "on Amepted*'4� <br />Dale \Z L Area lr i Employee IDtf��' " <br />Gout inspectionDate ❑ SpEC1 Well Permit <br />Pump Inspection Dale Ll WAIVER Received <br />Soil Eoring Inspection Ely Date Constructed Well Depth ft <br />COMMENTS <br />IN <br />PE <br />SC Received <br />CheekW <br />Amount Permit/ Invoice# <br />Date <br />WellID9 <br />Codes <br />Info By <br />Cash <br />Remitted Service Requost.A <br />3—C <br />i <br />3�t I S <br />003u�61 <br />Received Time Dec, 5. 2014 3:47FM Nc1,7664 <br />