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WI)O-LUPU P V°Gfl�N u :a�N,)OACiUliq COUNTY[-:NVIRONMENTAL I-aEAL T l-1 i)EP T 9668 East Hazelton Avenue-STOCIc 1 ON CA 95205-6232 - (209)468-3420 NEIN-IREFUND,ABLL PERMIT CALF 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED �V CITY/ZIP J, OGK�V Com'f ��ZQ z A Jor,ADDRESS 14A4�sM GROSS STREET TA r F tilPl`! I Z PARCEL SIzE LAND USE APPLICATION;'# /� / m (� V.7 rn fOWNERi�IANIE A /�f _ PHONE OvVNER:�.DDRESs y �. G ff dr✓.yEL S j CITY/STATE/MP- S To c k TyA✓ e A 9 r 2 o 4- i GONTRACTOR lj vLF Sff/t,C a tiJl(hv4 �7�P1-10NE /' G GONIPACTORPODRESS 334 Z '1 -f' TOCE4AL4 gog0 C.;I r/STATEIzIP 12AAlGt4o zO"0✓4! y� / ,5UI3C0NTRACTOR PHONE SUSCONTRACrOR;ADDRESS CITY/."NATE/ZIP r LICENSE AC-57 ❑ C-61 ❑ D-09 0 other Numar-R /�G q Z!# EXPIRATION DAT E GEOGRAPHICAL INFORMATION: Coordinates X Y Township Ranee Section INTENDED USE 0 Domestic/Private ❑ irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring V.Soil Sampling/Characterization ❑ Public Water System If different from Owner: Water System Name —CorkName or Phone Number TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification 0 Other 0 Monitoring Well(s) ;F#of wells 0 Soil Boring(s) #of borings $-Geotechnical --4 of borings 0 Out-Of-Service Well 0 Out-Of-Service Well Renewal ❑ Cross-Connection Repair / / e,. dJ 4 _ 0 New PUrnp ❑ Pump Replacement 0 Pump Repair 0 Raise Well Casing VVELL CONSTRUCTION -- Drilling i71ethod 0 Mud Rotary 0 Air Rotary 0 Auger 0 Cable Tool ❑ Push Point ❑ Other _ Proposed Well Depth 9fl it E=xcavation in diameter ❑ Open Bottom 0 Gravel PaddGravel Size in diameter 0 Conductor Casing in diameter / Conductor Casing Depth ft VVell Casing Diameter in Thickness/Gauge/ASTM Sched 0 Steel ❑ Plastic ❑ Stainless Steel ❑ Other G VOL1t Seal Depth_ C'LS_ft 1.Neat Cement(94 Ih hag/5-10 gal water) 0 Sand Cement sack mixl7 gal water ❑ Bentonite(20%solids) ❑ Other GroW.Placement Method ❑ Pumped 0 Free Fall Other ❑ Retardant/Accelerator(name) PEDESTAL Instalied By ❑ Driller ❑ Pump Contractor 0 Other ❑ Concrete Pedestal Dimensions:Width ft Length it Thick in 0 Christy Box 0 Stove Pipe PUMP ❑ Submersible0 Turbine 0 Other HP Pump Set ft `Standing Water Level ft II 1HEREBY CEPTlFY THAT I HAVE PREPARED THIS APPLICATION AND THAT *FFIE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICE=NSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND TRA-1 .1 AM IN COMPLIANCE WITH ALL IWORKERS CM01PENSATION LAWS. MINIMUM HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS SIGNED TITLE ��/v rd'( '� �^ DATENE irwiu --- — — -- — — — — — — — -- — --- --- --- — ---- — — — — -- — — — — — -- -WALnjQEpAjtTA11ENT 0E• ? ;11:TMENT U E N L Y Application Accepted By Date Area-.2'/.?'1Employee ID# Grout Inspection By Date SPECIAL WeH Permit Pump Inspection By Date WAIVER Received Soil Boring Inspection By 1.0 Date Constructed Well Depth It COMMENTS PE Sc Received 1,`, Amount. Permit! Codes In-To By Cash Remitted Date Service Request Invoice 11 Well IDsI - 4 1 EHD 43.06 WELL/PUMP PERMIT 3/04/00