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Dec 03 07 11:01a Ken Gross 's & Pumps 2 '45-8584 p.2 <br /> WELL/PUMP PERMIT c <br /> SAN JOAQUIN COUNTY ENVIRON.v1ENTAL HEALTH DIEPARTMPNr Sus I'WRITER Avic 3"FL-STOCKTON CA 95202 -(209)4U-3420 <br /> NON-REFUNDABLE PERMIT [/EXPIRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS J i F� i. //�(iv/f�/�/�/-�y ' CITY(LIP A /y!�� 49. <br /> r J✓L�P+� <br /> CROSSSTREIrm _APN L1) L,' ARCFJ.SIZE�LAr%USE APPLICATIONIV <br /> OWNERNAME �IC� df.� r�Lbb t ! (:('7D71 PONE 3• 1`J <br /> OWNERADDRESS :.� �t // ` CITYISTAYFILIP �j Q <br /> CONTRACTOR tei 5�. �I G.L/ /�ij�PHONE /y-���/5w.•����L�/s6 <br /> CONTRACTOR ADDBP95:/-� ( �. /,1 (� � Nid.�. Crrr/STATPIZIP �-/(._(/[, Z!'1 `I✓� J�'� <br /> SUBCONTRACTOR ^��`•'7VT—` PHONE <br /> SUBCONTRACTOR ADDRESS Crnr/STATPJZIP <br /> LICENSE C-57 OC-61 C3 D-00 ❑Other NUMBERr�f��172 £.xPtttAmoii DATE ✓ <br /> CEOGRAPHICALINPORMATION: Coordinate! X Y Township Range Section_ <br /> a-iDPD USE OfDomestic/llrivate ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Samplirg/Charecterization <br /> Public Water System <br /> IfdiDrmu r—Owner. w4w symm xa= C-t.1 ane or x u <br /> TVPBOr,WORK Mew Well 0 Replacement Well 0 Well Alteration/Modification ❑Other <br /> ❑Monitoring Well(s) Mofwdls O,SoilBonng(s) Morborins. OGeotechnical torfermv <br /> ❑Qui-0f-Scrvice Well O Out-OrWell Renewal ❑Cnow-Connection Repair <br /> a Purnp 0 Purnp Replacement 0 Pump Repair <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary 0 Air Rotary E]Auger �'Cabk:Tod ]t 0 Push Point 13Other <br /> Proposed Well Depth L7 I ft Excavation ren diameter 169p.Bottom ❑Gravel Pack I Gravel Size in diemct:r -r <br /> ❑CoadactorCming indlameter / Conductor Casing Depth R •v <br /> Well Casltlg [>ianwter in Thicktle58/Oaoge/AS7M Sched�JZ> ! tel ❑Plastic ❑Stainless Simi 0 Other <br /> -112Graut Seal Depth, 0 00 R mYr 0 Neat Ceent(94 Gag 1.5-10 gni weer) ❑Sand Ccment /6.> • A— rack mbr/7 gd water <br /> 0Irk 0 Bentonite(20%solids) C3Manufachucr Spa%solids_% Name ❑Specs on File ❑Spccs Subrnivad <br /> Crtwt lBtxmat 04*Pmethod Pumpod D Free Fall ❑Other ❑Retardant/Acccle:alor(name) <br /> PEOESTAr. In uedey 'ller ❑Pump Contractor 1,3Other <br /> at'Iste Peds DElnendBaa:WkIQ ft length '` R thick in 0 Christy Box 0 Stove Pipe <br /> E02 ❑Submersible ❑Turbine DOther HP Pump Set fl Standing Water Levci B <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL RE DONE IN ACCORDANCE WITH SAN <br /> IOAQUIN COUNTY ORDINANCES,STATE LAW'S,AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MV 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. N <br /> StCNEq •-r��-"��.` ��'C-tet- E -.-.-F ... DATE/Z--. 3,:::! <br /> 7 t1 <br /> i <br /> FFj /V1 <br /> L `\ <br /> a. <br /> _ � r <br /> S <br /> DE PAR ENT USE ONLY <br /> Application ed By Dale -�( e Area Employee IDM J-�tV IIJ Z <br /> Grout Inspe Date �0�/o2i/ls7 ❑ SPECIALWell Peen it <br /> Pump Easpoction By_ Date ��s ❑ V1rA1VER Received <br /> Constructed Well Depth <br /> COMMENTS <br /> PE SC Received Ch ! Amount PermH/ <br /> Code& Info B emitted Date Service R cat K [nvoice M Wall TDM <br /> 4A4, I f0 Gin� 1 <br /> P9 C,5v Scl.� \ 390-0 Z -7 W100 0 7 ' <br /> rHD lSlal-00& � ���� Y/ELL tUMY PUMII <br /> `l J� <br />