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Jul 1715 12:14p Ken Gross Wells& Pumps 2097458584 p 2 <br /> ' WELUPUMP PERMIT <br /> SAN JOAQUIN C:uu4TY ENVIRONME,'YTAL HEALTH DEPARTMENT 1£66 EAST HAZELTON AVENUE•STOCKTON CA 95205-(209)4693620 <br /> NON-REFUNDABLE PERMIT CALL 209)953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> JoaADoREss ,2 W1 A " CrrrZP uA 1 4f 7 )c. <br /> n <br /> CROSS STREET � 'A'P--nN(/.l1�_�_a PARCEL SIZE c"S�0 LAND USE APPLICATION i} <br /> OfTNER NAME 3a7- <br /> R •i � v�VIi yy j �jZ ^PHONE �(Y <br /> ?+rqnA <br /> OWNER ADDRESS \`�L't' V tL CfTYrSTATErzIF b�t'�$f <br /> CONTRACTOR PHO <br /> CONTRACTOR ADDRESS -• � L// /^"Jr C1TYfST0 <br /> SU9CONTRACTOR (1De PHON'16E��1_(/�///I•2� -fJ k� <br /> .. <br /> SuscoNTRAcmrt ADDRESS CfTY1S�ATE'71P _ 1 L[�- �-Z V�V_� <br /> LICENSE 4,.'1x57 rr C-531 D-09 11 Other NUNBEft,7 Ex P1rU,T10N DATE ,{{ <br /> GEOGRAPHCAL INFOiLLIAT70N: Coordlnates X Y TownShip_ FumgO SOcticln <br /> INT"oEo UsF C Domesticl?dvate . getionlAg iuHtural 0 Industrial 0 Water Quality Maritoring 7 Soil Sa-nPl:ngfCharacterizaticn <br /> U Public Water System <br /> If ddl—I Iii—Owner r em mo mea rc u�rur w <br /> TYPE OF WORK - NeW Well 7 Replacernent Well C Wel AlteratiardModification Other_ <br /> c MonitoringWell(s) 1l of wells C SoilBoring(s) Setbonn0s n G=otednlc l =do" <br /> L Qul-OFSeroce Well C Out-OfService We11 Renewal c C ossConrtedion Repair <br /> -,y I.ew Pump 7 Pump Replacerren,. E Pump Repair Q Rase Well Casio <br /> WELL CONSTnucTI ON <br /> Drilling Method C MudRotary_ 7 Air Rotary C Auger able Tool C1PUsh P�Int C Other <br /> PnopOsod Well Depth <br /> _It Excavation in diameter _-OOpen Bottom 7 Gravel PackJGrEvel Sve in diarnetef <br /> O Conductor Casing in diameter / Conductor Casing DePE7J fl <br /> Well Casing Diamcler ilin_ Thickness/GaugelASTM Schell .SIeW r I Plastic n SlaiNess Steel r;Other <br /> GroutSeal Depth-14ft 0 Neal Cement(94 rb bag15-10 gal waver I-Sand Cement(?. 3 sack Wxrl gal viater <br /> U Bentonite(20%solids) C Other <br /> (Grout PlamrnentMethod 0 Pumped 3 Free Fall 0 Other =Reradant IA.ccelerator(name) <br /> PEDESTAL Installed By r,DrUer r:Pump Contactor Tl Other I <br /> I'Concrete Pedestal cpimenslons:WtdBt It Length ft Thick in Christy Borz ,.,Stove Pipe <br /> PNbtP C SubmersiG,. Turbme ❑Other HP= Pump Set ft Standing Water Lavel ft <br /> 1 HEREBY CERTIFY THAT I M <br /> AVE 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 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS CO PENSA710 VIS. <br /> UM 24 OU DVANCE NOTICE REQUIRED FO INSPECTI01tS-PLEASE CALL(209)95P-7697 <br /> stcNm TrrLE ,I,`r1.Qiy— DATE <br /> i <br /> i <br /> t Ii <br /> f I <br /> Dot <br /> I <br /> I I <br /> Ii 1 <br /> I MEN'r <br /> 2015 <br /> D rAL <br /> i r�FN7 <br /> I <br /> I <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date _14Z�T Area V CG Emp:oyee IDg <br /> Grout Inspea 1 B s' Date 11'1_2x1&_- ❑ SPECIAL Well POITTIR <br /> Pump Inspoctlon By f\ " L Date V`4 i l ,1 ('� ❑ WAIVER Received r <br /> Soil Boring lrpection By Date Constructed Well Depth ft <br /> COMMEt4 S c Yom` / _ i -/ cc <br /> ,,,A <br /> _.h 7u cN /lir l /, f/u a•vt , �✓ "" <br /> PE SC Received Checkv Amount Permit! <br /> Codes Info B Cash Remitted Date Sery ice Req uest# lnvoic9H Well <br /> I' '� r oZ Z <br /> P�a-* <br /> END 43-W = -%�,'� W__L�UYP PEANrT <br /> Received Time Jul, 17, 2015 12 :20PM No. 9160 ) <br />