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Sep 30 14 12.08p Ken Gross Wells& Pumps 2097458584 p.3 <br /> WELVPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENviRONNEWAL HEALTH DEPARTMENT 1868 FAST HAZELTONAVElNUE-STOCKTON CA 95205-(209)465"Zo <br /> NON-REFUNDABLE PERmrr CALL 209 953 7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS { �. n <br /> y CTyrdP <br /> CROSS SmuE r V L V APN (JL- � ,�,Ll,� (Jt D o <br /> 1 ACEL SQE LLgND IJSE APP ATt # rn <br /> OWNERI`&ME <br /> OWNER ADDRESS - ✓ jig L9// CIWSTATEMP <br /> CONTRACTOR /-� r L PHO Y//;;, <br /> CONTRAC-'OR ADDRESS rAX CrTYfSTATE121P��"F_r <br /> I <br /> SUBCONTRACTOR <br /> PHONE <br /> SUBCONTRACTOR ADDRESS CIfTTY/STATE^r7P <br /> LICENSE G57 C 61 rl D-09 Other NUMMR-5✓b / }'EXPIRATION DATE <br /> GeoC cALINFOPMATIOPC Coordinates X y Townshi <br /> P Rango Section <br /> UNTEN OUSE 0 DomesticrPrivale urigatioNAgriarlW ral ❑Industrial O Water Ouafiy f✓oniloring 7 Sod Sam lin , a✓ L <br /> p g1Cha2cle izaGon r M .4- C <br /> L PubticWaterSysiam �+ u _ <br /> a d,ff.mnl from Owner. r em am° am°or ,orw CD V7 <br /> qL <br /> TYPE OF WOR Well 7 Replacement Well C Well AJleralionAIoddficatonCn f <br /> G Other -� <br /> Monitoring Well(s) Kcfwells - Soil Borings) °fbOe`�' Il Geotechnical *°r°0°°� <br /> r, Out-Of-Servb--Well C Out-OrServfce Well Reneval G Cross-Connection Repair <br /> IJ NewPump J PUMD Re laceIrent C PUMP Repair Wru CONSTAUCTON 0 Raise Well Cali �Z"-J <br /> �> C" <br /> � � Q7 <br /> Drilling Method C Mud Ro ry -r Air Rotary C AugerCable Tool O Push Pant C other Cl) <br /> z <br /> / tl� <br /> Proposed Well Dep <br /> It EzCavelion in diameter pen Bottom D Gravel Pack/Gravel Size in diarnmer CD C.1 .ro <br /> O COndL=tcr Casing in diameter f ConduGor 'ng Depth fl 4:Cif . C.: <br /> Well Casing Diameter ZtIT Thickness/Gauge/ASTM Sched ^ C0) <br /> Steel n Plastic n Slainless Steel F Other LYJ L�- <br /> GroatSea l Depth ft f+Neat Cement(941D 6agll-10 gal wafer) a Sand Cement sack rrdxrT gal >-, <br /> C Bentonite(20%solids) 0 Other -ta, CZ <br /> Grout Placement 9lethod VPumped A Free Fall 0 Other =Retardant/Accelerator(name) 4w C O <br /> +r CID i <br /> IPEDE4TAL Installed 8 Her n Pump Contractor it OCter <br /> Concrete edesral Dimensions Width R Lengih It Thick in -1 Chri Box -1 Stove PipB (-=J <br /> PUMP n Submersibles Turbine 7 Other HP Pump Set ft Standing 'ater leve' - <br /> tAL._ Ca L <br /> J HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH 9A + <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE it <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUMUM 24�DVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-76977 <br /> SIG— <br /> Y — DATE <br /> IJ I I PA <br /> ,i <<' <br /> RF MFNT <br /> C AFD <br /> SEP 3 d <br /> IIFr sr <br /> CY ■` f` Tf .2j 1 DEPART ENT <br /> ��USE <br /> � 0 Y C i <br /> A ed By .� Date 11 y-Y 1 Area FsTaloyee I D'd /�x�� <br /> 1 �p� G InspectionBr Date U S�e11 PerTnit <br /> Pump In:Son By Date 0 WAIVER Received <br /> SNI Boring Inspection By Dale Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received CheokW Amount Permit] <br /> Codes InfoBY Cash Remitted, Date Service Request Invoice* WeNIw <br /> ENO 4300 <br /> 41=12 W-c L RJMP PERMIT <br /> Received Time Sep, 30, 2014 12 : 29FM No- 7183 <br />