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%/ WELL/PUMP PERMIT ECE #10050 <br /> SAx JoADIAN Courm EwRostu MAL HEALTH DEPT 1868 East Huallon Avenue-STo nciN CA 952054232-(209)483-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES}YEAR FROM DATE ISSUED " <br /> JoBAooREss 3250 W. GRANT LINE ROAD CRymp TRACY. CA 95377 <br /> CROSSSTREET S. LAMMERS ROAD APN 238-600-06 PAR4ELSRE_----LANDU9EAPPLIcAItON! N/A <br /> OMERNAME COSTCO WHOLESALE 425-313-8100 <br /> OmERADoREas P.O. BOX 35005 CMISTATEMP SEATTLE, WA 98124-3405 W <br /> N <br /> cox cToR JONES COVEY GROUP, INC. PHONE 909-972-7581 to <br /> 0 <br /> COMRACTORADORE38 9595 LUCAS RANCH ROAD #100 ClrviSTATEmP RANTCRO CUCAMONGA, CA 91730 <br /> SUBCONTRACTOR LEAK DETECTION TECHNOLOGIES LLC PxoNE 520-207-4878 <br /> 1400 EAST PASEO PAVON <br /> SUBCONTMCTOR AOOREBS CRY1$TATE17lP TUCSON, AZ 85718 H7H7H7.., <br /> LIOENSE I I C-57 11 G81 110.09 1 ogler NUMBER 804431 EAPIRAVONDATE 8/31/2013 <br /> GEOGRAPHICAL INFORMATION: CoordinatesX Y Towoshlp_ Range_ Section_ <br /> r <br /> INTENDED USE ]DomesSr/Pdvele OlrtigatioNAgriwllwal nCITMusWel ]Walef OuantyMOn3aing ]Son Samplthg/ChereUerizaUon <br /> ]Puonc Wat"Syslem 'LI�y1 <br /> R6r/alaMawn OeDar. rr am amA « <br /> TYPEOFWORN ]New Wen D Replacement Well c Well AltereOon/Mod'13caeon XOlher ELD MONITORING p <br /> ]Monitoring Wen($)_Sofvrens DSoil Badry(s) sofww. cGeolechnical awborso <br /> ]Out-Of-SerAw Well c Out-(HServko Well Renewal D Cross-Connecllon Repair <br /> ]New Pump ]Purnp Repiacernent u Pump Repair 0 Raise Well Casing <br /> u H <br /> Ddllin0 Method ]M Air R0N ry [Auger D Cebie To" D Push Point ] Other <br /> Proposetl Weil DepU ft In diameter 0 Open Be vel Pack Gravel She In diameter <br /> 1 Conductor Casing_In diameter R <br /> Wall Casing Diameter_In Thickness/Geuge/AS L Plastic D Stei(ness Steal D Other <br /> Grout Seal Depth al Cement(94 to AB9Y5-d0 gal writer) 0San sackmtd7galwater <br /> 0%solids) ]Other <br /> ament Method U Pumped U Free Fe3 u O3rer i Retardant/Acuelerelm(nama) Un <br /> W <br /> ED£s er v <br /> anti �T <br /> uM <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS,AND RULES ANO REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT i AM IN COMPLIANCE WITH ALL <br /> WORKERS C MPENSATION S. <br /> U 2 H UR ADVANCENOTIC R IR DFO IN CTIONS <br /> &ONE 'a An T/21/2073 <br /> Fit F-61 <br /> R <br /> O,EPAfRTMENT SE ONLY <br /> Application Accepted ByDate C 7'Y Area __ Employee IDS � <br /> Grout inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> San Boring Inspection By Date Constructed Well Depth n <br /> COMMENTS <br /> PE SC Received hec Amount ata am Invoke Invoke Well IW <br /> Codes Into as Remitted Servica Ra usetis <br /> 3 <br /> 115, o -Y <br /> E 04soe Yna1IPOMPPERMR <br /> emuoe <br />