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Jul 171512;14p Ken Gross Wells&Pumps 2097458584 p.2 <br /> 1 (7D - .� <br /> • WELUPUMP PERMIT <br /> SAN.IoAwN COUNTY ENVIRONMENTAL.HEALTH DEPARTIrENT 1£66 EAST HAZU-TON AVENUE-STOCKTON CA 95205-(20914613-3624 <br /> NON-REFUNDABLE PERMIT CALL 209 9$3-7697 FOR INSPECTIONS EXPIRES 9 YEAR FR00.1 DA7E ISSUED <br /> m <br /> JOB Aowtass CYTY/m ////P� <br /> CROSSSTREET_ Cl�}VYI1�l� APN��(�/7�—P✓! PARCELSIZE&-U LAND USE APPLICATION N -I-0 _ <br /> OWNER NAIAE '• , r`J JZl/U T� t �� ^ — 131 <br /> 3-3941, <br /> V ,`�q- 111 PHONE <br /> •+ i� {� y�>� �j eA <br /> OWNERADDR;: `i \ (L "V / CnV/STAIErZJF t k'4"' ✓ /vt <br /> CONTRACTOR G PHO (// � JI <br /> CONTRACTOR ADDRESS Q • �LJ/ / (/7/ N �!✓��LV I CITYfSTATFJ7JP . lj/J 5 <br /> SUBCONTRACTOR `� Ott 0 PHONE/41 /- -y/--� ql..� <br /> SUBCONTRACMI't ADDRESS I % C"VSTATE7M- �Li w" - _-- �w l <br /> LICENSE P 17 n C-61 0-09 rl Other NUYBER�vt� ExPiRATION DATe <br /> GEOGRAPHICALINFORMA7ION: CcordlnatesX Y Township_ RangO Section_ <br /> INTENDED UsE C Domestic/Pdvate getionfAgriadtural ❑Industrial ➢Water Quality Ma0oring �Soil SamplinglChararterization <br /> U Public Water System L <br /> If different fi—O—W. r em me me or rw r <br /> TYPE OF WORK New Well �]Replacement Well C Well Alteration/Modification i Other_ ._ <br /> r Monitoring Well(s) N of wells r Soil Boring($) aatbwnps n GeotecMlral 3aG°0*VS <br /> tLQut-Or-Semce Well C Out-Of-Service Well Renewal ClCrossn <br /> Cartection Repair <br /> I New Pump J Pump Replacement, C Pump Repair D Use Well Casio <br /> WELL CONSTRUCT ON <br /> Drilling Method = Mud Rotary :1Air Rota-y --Auger able Tool ❑Push P�Int C Other <br /> Proposed Well Depth 4' _ft Excavation in diameter _Open Bottom 7 Gravel Pack/Gravel Size in diarneter <br /> C Conductor Casing in diameter / Conductor Casing Depttl n <br /> Well Casing Diameter in Thickness/GaugalASTM Sched /Bleat r1 Plastic n StaiNess Steel r:•Other <br /> GroutSeal Depth_-6_�579 ft D Neal Cement(94(b bag6-10 gal wa.edSand Cement_`fj,5 sacl:mieT gal water <br /> LI Bentonite(20%solids) ❑Other / <br /> Grout Placement Method O Pumped C FreeFall ❑Other =RenodantTAcceleralor(name) <br /> P606STAL Installed By n Driller r:Pump Contractor n Other <br /> I'.Concrete Pedestal nDimenslons:Wilth fl Length ft Thck in Christy Box �Stove Pipe <br /> PUMP C SibmersibilaIj Tu101ne ❑Other HP Pump Set R Standing Water Level R <br /> 1 HEREBY CERTIFY THAT I 14AVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS,AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE MTH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WFTH ALL <br /> WORKERS COlyPENSATIO YS <br /> N . <br /> MUM 24 OU DVANCE NOTICE REQUIRED FOR,tNSPECTlONS-PLEASE CALL(209)950-7"7 <br /> 7 <br /> SIGNED TITLE &A I P. DAA I <br /> I <br /> I <br /> IT <br /> 2015 <br /> Ll <br /> rMENr <br /> s <br /> DEPARTMENT USE ONLY <br /> Application:-pled B - Date � f Area IV CG Emp:oyee <br /> Grout Ipecti B J Date f ❑ SPECIAL Well Permit <br /> I Pump Inspec.By �t ' Date ❑ WAIvER Received r <br /> Soil Boring Iris ection By Date Constructed Well Depth <br /> COMMENTS Pi .� vvv✓✓✓� <br /> / L _ h u e- `pjCcY a s \ <br /> PE SC Received Cheeldd Amount Permit( Invoice N Well ID# <br /> Codes IDfD B Cash Remitted Date Service Re uest# <br /> Lxx� <br /> eD v `3 d 2 <br /> END 41,oe WE1 rPUUP PER MIT <br /> 6 <br /> Received Time Jul, 17, 2015 12 , 20PM No. 9160 J - <br />