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SAN JOAQUIN COUNTY ElnATIONMENTA1,AJOLTH DEPARTMENT 600 EAST MAIN STN KTON CA 96202 209 460 <br />JoeADDnrss 1153 Lincoln Blvd <br />CnOSS STREET API <br />OWNER NAME Quick Stop ##138 <br />OWNEnaoortEss _1153 Lincoln Blvd <br />_ (209) 953-7697 FOR INSPECTIONS 1 YEAR FROM DATE ISSUED <br />C,nrLP Tracy/95376 <br />-2- 3 Z —' —7 0 — l (PARCEL SIZE LAND USE APPLIcATIDN m <br />PHONE <br />CrrYISTATErnp Tracy, CA 95376 <br />CONTRACTOR CGRS, Inc. 916-991-1100 <br />PHONE <br />CONTRACTOR ADDRESS 5444 Dry Creek Road i CITYISTATEM.. Sacramento, CA 95838 <br />SU13COWTRACTUR PHONE <br />SUBCONTRACTOR ADDRESS Cr YISTATEMP <br />LICENDE 11 C-57 11 C-61 11 D-09 I Other HAZ,A NUMBER S o 3 616 EXPIRATION DATE 1/31/10 <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Sactlon <br />INTENDED USE 7 DomeslirJPrivale D irrigallon/Agricultural C indusirlol 7 Water Quality Monitoring ] Soll SamplinglCharacierizallon <br />D Public Water System <br />If dllrcmnt hem Owner. n cr by4l.. eme an n arae or none um cr <br />n <br />TYPE OF WORK 7 New Well D Replacement Welt C Well A1lerallonTModiiicallon /%]'Olher <br />7 Monitoring Well(s) R of wells 0 Soil Baring(s) — s a' hodnas alechnlcal a othmin 6, <br />0 Out-01Service Well C Out -Of -Service Well Renewal 0 Cross -Connection Repair <br />0 New Pump D Pump Replacement C PumE Repair <br />WELL CONSTRUCTION <br />Drilling Method 7 Mud Rotary D AIr Rotary C Auger O Cable Tool O Push Palnl �--Other J 6k -(- <br />Proposed <br />-(-Proposed Wall Depth a Fxcavetlan In dlamoler O Open Bottom O Gravel PacidGravel Size In diameter <br />I Conductor Casing In diameter 7 Conductor Casing Depth R <br />Wall Casing Diameter_ In TlddmesslGougE/ASTMSchad Q Steel C Plastic O Stainless Steel 0 Other <br />Grout Seal Depth Il O Neel Cement (94 111 ba915-10 gal water) O Sand Cement sock mixl7 gal water <br />7 Bonlonlle (20% solids) J Other_ <br />Grout Placomant Method U Pumped U Free Fail U Other J Retardant I Accelerator (name) <br />PEDEGTAL Installed By 0 Driller Q Pump Contractor O Other <br />Concrete Pedestal Dlmonsions: Width It Lennih <br />It Thick in ❑Christy Box ❑ Stove Fipa <br />PUL!, -1 Submer-nidef] Turhinc C OUrer {-IP Pump Sel --Ii Siartiinr. 'lJUter Level R <br />I HEREBY CERTIFY TIiAT I HAVE PREPARED TiiIS APPLICATION AND TliAT THE WORK WILL BE DONE IN ACCORDANCE 1NITH SAM <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGUI-A-HONS. 1 ALSO CERTIFI! THAT IriY REQUIRED Lim.'SE ; <br />CURRENT AND ACTIVE Wirri -rHE CALIFORNIA CONTRACTORS STATE LICENSE BDARD AND THAT i ANI IN COI!fPL!ANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />f/MIM1�lIMUPJi 24 HOUR ADVANCE NOTICE REQUIRED FGR INSPECTIONS <br />SIGNED_ ( '✓ / ✓�' "fYTLE ��/ice!/•%:':✓<_ j()! LYi �UG <br />DAT[ <br />c VEr <br />D <br />12 2008 <br />A _YNTy <br />APplicallDn Accepted By / <br />DEPARTMENT USE LY <br />Date d <br />Area to �" Employee IDm <br />Jr <br />Grout Inspection By <br />Dale <br />SPECIAL Well Permit <br />Z?e <br />Pump Inspection By <br />Date <br />WAIVER Recelved <br />Soil Boring Inspection By <br />COMMENTS <br />Dale <br />Constructod Wall Depth <br />R <br />PE <br />SC <br />Info <br />Rocolvod <br />8 <br />Check#t <br />Cash <br />Amount <br />Ramltlod <br />Dato <br />Permit/Codes <br />Service Ra uasl S invoice N Wall IDd <br />Z?e <br />EHD d3-06 <br />M We7 <br />WELL -PUMP PERMIT <br />