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WELL/PUMP PERMIT SAN JOAQUIN COOerrY EhVIRONA¢MAL RE Irll DEPAR� #13867 600 E.Mdn Street-STOCR[ON CA 95203 -(209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPUM I YEAR FROM DATE ISSUED E.Kf6{6W JOSADDR[ss •fir- C1TY)2'n Stockton 95215 I it CROSS STREDT Gillis Road - APN 103-060-13 PARCELSIZE S LANDUsgwnuCAnong OWNER NAbre Roger 6Maria Casillas - - " - PBONg 465-2138 owNRa ADORE45 ` P:O. 'Box 5779 Crry)STATTJZv Stockton. EA 95205 clym TpR Delta Pump . - _ PHONE 209-466-9625 CONTRACDIRADDarss 646 S. California Street C /STATVGR Stockton CA 95203 SUBCONTRACTOR PIIONg SUBCONTRACTOR ADDRESS CMISTATPJLIP LICENSE 0C-57 XXC•61 13D•09 ❑Other NUMBER 724778 Eg ,,,,TONDATE 08/12- GEOGRAPHICAL INFORMATION: Coordinala X V Township_ Range_ Seetleo_ INIYNDED Us[ DomenirRrivau Cl lwiptontAgricwtural OlodwMsl ❑Water Quality Monitoring O Soil Sempling/Chenewintion .:..C7 Publk WeserSyyratteem_r�' _ ..r- _ �.•�• - - M.. smem� ee IrNgaw[bm Pry tltr n ar c TWEOFWORR ❑New Well ❑Replacement Well ❑Well ADention/Modificadon 13 Other ❑Monitoring Well(s) Mofwalls [3 Sod Boring(,) I.fbodgs ❑Gootechnial—sRftwdogr O Out-ofScrAw Well ❑OwA(Smke Well Renewal Cl CrowCohmeDdon Repair Q ❑New Purno M Pump Re leeemest 0 FUW Repair WELLCONSIRUCDON ' DrIIReg Method ❑Mud Rosary OAir Rotary OAnger QCoble Tool OPWAPOW OOther Proposed Wee DepthR Ezwvalion kh dlameVs ❑Open Bottom O Onvel Peck I Gran)Size In dlameur ❑Cooduemt CuiDg a diuneler f CooduelorCuing Depth-=- — : - R Well Cuing Dumner_In Tbicknas/Oaugc/ASTM Schcd. -O Steel O Ptsstu O Stainless Steel ❑Other 'Great Sal. Depth r ..it ❑Nat Cement(94166ag/540 p/waerJ -❑Sand Cement .rack seer/70 wiser S' O Bentonite(20%solids) ❑Manufaemmr Spee%solids_% Name ❑Spem oD File ❑Spew Submined Groat Placement Method ❑Pum' OFra Pall ❑Other Cl Retarders I Accelerator(maw) i PlDESTAL Iesulled By 13 Driller C3 Pump Comrenor ❑ Other ❑Caemte Pedestal Dlmaslooa:Width fl Length- R'Mick N ❑Christy Bo: ❑Sbn PI ( Mubmen@b OTolem. OOther HP Pu Sot flSundwg Waterlevel fl I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS, AND RULES AND REGULATIONS. 1 ALSO CERTDY THAT MY REQUMD LICENSE IS , CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL i WORKERS COMPENSATION LAWS �.� 24 HOUR ADVANCE NOTICE.REQUIREDFOR[NSI?-E=ONS - slcNea` TITLE CEO DATE 12/09/11 i 1� l ON AL DEPARTMENT USE ONLY / App)icadoo Accepted By Dau 12-1f3141 Area Employee IDS 54 Grow Inspection By Date O SPECIAL WeIdPermit Pump Inspection Date /L/5'!. OWAIVER Recelved Coatrswd Well Depth R ,`gyp COMMENTS c - PE SC Reeelved C cc Amm AIN Coda "PertaiU - InrolaY WeIi IDV Coda 6Te .B Rem lNed - errlee Re ua -S - 3 I