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it 1 S(oi^ 15-247— 17 0%-\ CoxF1 s�WSTOM tr <br /> btHNo`) <br /> WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENNNONYEVAL HEALTH DEPARTMENT 1868 EA HAxELToNAvEsue-STOCKTON CA 95205-I209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953.7697 FOR INSpECT1ONs EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADOREW 3637 w Stewart Rd(South of Cohen Road) CnY2P Lathrop, CA, 95330 r <br /> earadiee Road / Cohen Road 1322001 to 004 2 <br /> CROW 3TMP2T APN PMca SQE 535 LSIro Use APPLICATNHte <br /> OWNER NAW Susan Dell'Osso <br /> L,e.+adr z 1� HEooAR 22009-879-7900 <br /> O,W,ADORess 73 W. Stewart Road/�A �f- �- Cm/STATE2P aLat rAoLp C i <br /> CoHTsAc1oR California Push Technologies, Inc. PHONE 510-357-3677 <br /> CONT ce ADONM 820 Aladdin Avenue CrrWSTATEMP San Leandro. CA. 94577 <br /> SuscomeAcioe PHose <br /> SueeaxmAciox Ansseas CmISTATEZP <br /> LKesse X C-67 _Cat _D-09 " Other NUNSER 884827 ENPMATON DATE <br /> GEo "NKALIHFoeNAT ; COp[thea% 37'807954° Y-121.342948° Township— Renga_ Section_ <br /> INTENDED Use ' DonNstMlPnvale ImgetioNADicullural -Industrial Water Quality Monitoring X Soil SzmplingrChalsctematon <br /> - PublicWatw System <br /> nam«m aeon ow°.r: ar r a e°w me D, ,. u° <br /> Tl,p OFWORK New Well " Replacement Well -WNI AReralioNModiicabon Other <br /> Morilonng Wells) Bof wells Soll Buring(s) eofeemyr XGeotechnical 11 rereo,.q. <br /> _ Out-OfService Well Out-Of-Service Well Personal l a CrossConneclion Repair <br /> New Pum - PU.p Replapplanent r PU.p Repair Raise Well Casio <br /> WELL CONITMIMN N <br /> Drilling Method Mud Rotary Air ROtery Auger Cable Tool X Push Poiret Oth <br /> Pmpowd Well Depth30 to 1001 Excavation tin In diarneler _Open Bottom _Gravel Pacs/Grw el Size in diameter <br /> Conducto,CWng Inaiameter / Ccndudor Casing Depm N <br /> Well Casing Di unew In ThKlurawfGauge/ASTMSched -S!ai -Plastic . Stainless Sleet Other <br /> GroutSeal Deps,30 to 1001 X Neat Conant f94 I6 bagr610 gal wales) Send Camenl sad aWA77 gal water <br /> - Bentonite(2D%sol Omer <br /> Grout Placement Method XPumped Free Fell Other _Retardant/Aroisrwor(nsme) <br /> PepearAL InWlled By Omer Pump Conueclor Other <br /> Concme P40UNI DInN nsbM:WWII_h Length ft ThcR In Christy Box stove Pipe <br /> PUYP -SuMnersible- Turbine -Other HP Pump SN K Standing Water Level R <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 /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 4 H ADVANCE NOTICE REQUIRED FOR INSPECTIONS•PLEASE CALL(209)953.7697 <br /> SMNED Tme Staff Engineer DAa 3-14-17 <br /> EI�ED <br /> 2017 <br /> D f MY <br /> �TMS7YT <br /> HENT U E NLY <br /> Application Accepted By =!' teNU Area _ Employee IDN GO✓�"N/aVl/"/ <br /> Groin Inspection By Data SPECIAL W II Permit t <br /> Pump Inspection By Data WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth R <br /> COMMENTS <br /> PE SC Recaiwd Checks/ Ampunt Dale Pemitl Imolni Well 1110 <br /> Coda Into B ash Remitted Data uest8 <br /> l'SD WIN <br /> EKDarN O/ <br /> w/na eh1L a'UE1P PeRMIT <br />