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1 e WELLIPUMP PERMIT <br /> SAN JoADuM COUNTY ENHAONM6NTAL HEALTH DEPT 915614 1668 Ead HuWton Avenue-STOCKroN CA 95205.8232-(208)468.1420 <br /> NON-FZEFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED M <br /> JDa ADDREaS <br /> 12227 W. Larch Road C"ILP T 95304 �DD <br /> b <br /> v <br /> CROSS STREET NaElee Road APN 2�• DUse APPIIWTIDw# 9 <br /> OWNER NAUE Mary 7e. 'Foeb, PHONE <br /> 835-0157... <br /> OWNER ADDRESS same CRYISTATFRID <br /> CONTRAOTOR Delta EMP PHONE I09-466-9625 <br /> CONTRADTORADOREss 646 S. California Street CRYISTATEMP Stockton, CA 95203 <br /> SVSOON GTOR PHONE <br /> SUSCONTRACTOR ADDRESS CTwSTATFZP <br /> LICENSE 0 C-57 E C-61 D D-09 0 Other NUNaER 724776 EXPIRATION DAT! 26/14 <br /> -_ _ .-. _ Townshlpt Ren9o_cUon_ --- <br /> t�r—GEODRPVNICAeWFORYM110M:-2E00rEInetH" -.-� ., ... ... ..- <br /> ( INTEwo6D USE OomestlGPrivals 0 nigatlan/Agdculturel�O industrial O Water Quality Monitoring O Soil Sampling/Chwadierizn0an <br /> 1 U Public Water System a oto um <br /> SdIMnnllmm QVNG e m a <br /> I <br /> TYPE OF WORK C New Wen 0 Replacement Well 0 Well AlleretioNModifoe0on 0 Other <br /> it <br /> O Monitoring Well(a) N Of wells ❑Soil Boring(s) ea1hw1opi ❑Geotechnical PUMP, <br /> ❑Oul-OfSeMce Well t-OfService Well Renewal 0 Croas-Connton Repair P • INSTALL <br /> 0 New Pum 0 Pum Ra lecema P Repair o Raba Well CesIn BLEEDER VALVE <br /> We"CONBTRUCTON <br /> Drilling Madrod ❑Mud Rotary 0 Air Rotary O O Cable Tdd D Push Point 0 Other— <br /> Preto...d <br /> merProposed Well Dept It Excavation . . . . In diameter 0 Open Bottom O Gravel paek/Grevel Size In diameter <br /> D Conductor Casing In diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad ' 0 Steel O Plastic 0 Stainless Steel 'D Omer <br /> Grout Seal Depth fl 0 Neat Canlant(84/b beg^510 gat water) 0 Sand Convent sack Rt/x/7 gal water <br /> ❑Bentonita(20%3ollds)' 00ther <br /> Grout Placement Method O Pumpad O Free Fag D Other D Retanlant/Accaleralor(name) <br /> 1p0DEATAy Installed By DDriller ❑Pump Contractor ❑ Other <br /> ..crate Pedestal Dlmenslons:Width R Length ItThlck In, 0 Chdsly Boz ❑Stave Pipe <br /> pUMp bmarsibieO Turbine 0 Other. HP 1Pump at NA 8 Standing Walter Level A ft <br /> I HEREB C FY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN UNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT-AND ACTIVE,WITH THE,CALIFORNIA_CONTRACTORS STATE IJQENSE_BOARO,AND THAT.I-At INlC,OMPLIA_NCE_WITH.ALL , <br /> WORKERS COMPI:PTSATION LAWS. <br /> IMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> gIaNED TrrLE CEO DATE 07/31/13 <br /> l <br /> 11-2113 <br /> zt <br /> n._ - teu mj 1,1111 at IN C-4 a <br /> VI <br /> 4ENL H k A T_ <br /> i <br /> DEPARTMENT S NLY <br /> k <br /> Application Accepted BY �' ���` Oale � Are. ' EmIpl.Yoe ION e+lI <br /> Grout Inspec on By Date SPECIAL Well Permit <br /> !I .Pumpinapecdon By Defe o WAIVERReceived <br /> 1 Son Boring I pe n BY Date -Cdnewcbd Well DePlh _ 11 <br /> COMMENTS <br /> PE SC' Received hoc Amount - ---U�b- Pv—N` mvaNet Well W# <br /> Code. Int B Cash Remitted Service Ra ued6 <br /> 0y(Z,d0677 53' <br /> I EHO AYOe WBLRIIMPiFRMr <br /> sows <br />