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WELL/PUMP PERMIT <br />SAN JoAouw CouNTv ERN11DNMEMAL HEALTH OEPARTMEIR 1166 EAST HATTITON AVENUE• STOCKTON CA 852056232(70714634UID <br />1pe Aomuss 1781 E Grant Line Rd <br />clrxrm• Tracy / 95304 <br />CROs SmEM N Chdaman Rd APN 213-O70-39000 <br />PARCEL Sim 11.4 ACLARD USE APPLICATOR a <br />Darwin NAME MBrty Marilyn Trust <br />P"O"E <br />DAMN AGDREas 1681 E Grant Line Road <br />CRYI$1ATFT2P Tracy / CA / 95304 <br />CWONAc roR Cuesta Geo. Inc. <br />pNO/E (925) 872-1248 <br />CONTMCfok AOORESS 2709 Kapolua Court <br />GTIISTATEf2P Fairfteld / CA 194534 <br />-sUm KTR—owcONAULtANT Comentons Earth Group <br />_ _ P—..0 (4081 245..1800 <br />SUSCOItR.LCTOWCONSULTANI ADORLM 1259 Oakmad Parkway <br />CITYISTATEIZP Sunnyvale I CA 194085 <br />LIC SE XC•57 C-61 U-09 Othm <br />NUMBER 1043431 EAPmATKINDATE 8/31/2022 <br />BALRG PARTY: C` OVWEA J Cown.0 RI X SUBCONTIIACTO"ONSULTART <br />DOMEsnc WELL SAMPLING: t" General AlmeraL'CoidorrTl Bacteria (4391) -: Olhromorhloroprapane (4392) L ATsdnic (4393) <br />!r?,NQ€D WE ' Dommt IPEInb M1GADonlAOrindnral - tnh.zMRl Waw Oualry Maulodry X Sol SRmpinyCnorgdorvACon <br />Public WA!er System <br />A 1PAnr1� � Vt—Syi'Nero [uLO NrawoPnw K^fW <br />TPe OP WoaK Now Wm Roel—pal Weil WeA ARerBhauLkKI,f—eon ' o0or <br />Monitoriq Wens) aotv.ems - Sal Boong(n) aerwlp XGeolochnlc4l 2 ear eorps <br />- Out-Ol- en Wan Ou401SsrWw Well Ranewsi ., Cro Conrocucn Repa;r <br />New P—D Pump R wmen: Purmp Repair a Rake Wal Cml <br />WELLCow-r on. <br />Drllllnq Malhod " Mutl ftaay All HCtuy It Augm _ C bo Toa . Push Panl CI 011— <br />Proposed WAIT Deem 75-40 it Exr Slew 6.3 In du aw _ Opal, Borten C G-0 PaCSJGr—' Sl- In dlametnr <br />COnducla Cavng ndumeter I Conductor Casing Daum IT <br />Wall Casing Dumaw _ h ThlcJ n—'GargNASTM S hw Stool = Plastic : Stalala" Sleet - Omer <br />Grout Seal Depth R X Neat Cement (94 11 DelySiO pal —for) Sand Cemonl SACk a/07 gal ware+ <br />B mtoaite (20X solids) - Ou ar <br />Grout Pla—M Method PumCed Frac Feu X oma+ Tronft Grout Rcurdem I Aw ICM&Cr (awTra) <br />DFsx tnaulmd By : ONkr Pump Conuactor Omar <br />Concnu P.1 -tel :DI—)...: With n Length It Thi k In J Chrkty Box I] Stow Plpe <br />PUMP -' Suane aa- Turmno Other HP Pump Sal R SUM'vr0 W'aer level R <br />I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAGUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REOUIREO LICENSE 1$ <br />CURRENT AND ACTIVE WITH THE CALIFORr CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMP NATION LAWS, <br />MIN l 48 OUR AI C NOT;C'•_ c;�:GLV+�c(1 F N U�JL�(1f/ tL (209 9 j3-76 7 <br />$u�D Trlu `_. T/ •�41 DATE ` � <br />PE SC R.C.iv Checkai Amount DAN Parmlu Involca a wait 100 <br />Codes Into 9 h Remit S"CaRaeum&tal <br />I �� F714'0 <br />► <br />n+O rxae antaoTE <br />A'ELL,PUNPPERAAT <br />PAYMENT <br />RECEIVED <br />NAR 18 2022 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />DEP, R ENT U 'E O LY <br />Appllrallon AcCepted By <br />Delo <br />ae Em.41. <br />Grout lespeaw By <br />r Dato <br />- SPECIAL Well Penit <br />Tl <br />PuImpedlon By <br />Pam <br />D ate <br />WAIVER Received <br />Solt Boling festal By <br />Date <br />Constmelad Well Depth <br />IT <br />COMMENTS <br />PE SC R.C.iv Checkai Amount DAN Parmlu Involca a wait 100 <br />Codes Into 9 h Remit S"CaRaeum&tal <br />I �� F714'0 <br />► <br />n+O rxae antaoTE <br />A'ELL,PUNPPERAAT <br />PAYMENT <br />RECEIVED <br />NAR 18 2022 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />