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•,� 19006 TAP- „"A SCtkvn I-(l-.I� <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue - STOCKTON CA 95205-6232 - (209) 468-3420 <br />NUN-KEFUNDABLE PERMIT GALL (Z09) 953-7597 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 9501 E . FRENCH CAMP RD. clTY/zIP MANTECA 95336 <br />CROSS STREET ,S . AUSTIN RD. APN2 01 —09-010 PARCEL SIZE 5 8 . 4 BAND USE APPLICATION # <br />OWNER NAME DEGRAAF RANCH ��dZZ r �M/r _ PHONE 2 0 9 608-0123 <br />OWNER ADDRESS E. FRENCH CAMP RD. CITY/STATE/ZIP MANTECA CA 95336 <br />CONTRACTOR Delta Pump-STo rKmN ARMATURF & MOTOR WORKS 11"6>=. 209-466-9625` <br />CONTRACTOR ADDRESS 646 S. California Street CITY/STATE/ZIP Stockton, CA 95203 <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br />LICENSE ❑ C-57 X C-61 ❑ D-09 ❑ Other NUMBER 724778 EXPIRATION DATE 08/I1 <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br />NTENDED USE CkRomestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br />❑ Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings ❑ Geotechnical # of borings <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />.vCizNew Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casino <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth ft ❑ Neat Cement (94 Ib bag/5-90 gal water) ❑ Sand Cement sack mix/7 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />❑ Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br />PUMP bmersible❑ Turbine ❑ Other HP Pump Set ft Standing Water Level 51 ft <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND 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 COMPENSATION LAWS. <br />67n2!: <br />24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br />SIGNED ��.•A TITLE CEO DATE1 / 9 / 2 017 <br />D­iEP RTMENT US ONLY <br />Application Accepted Date 1 I <br />Grout Inspection By Date <br />Pump Inspection By DateIV <br />Soil Boring Inspection By Date <br />COMMENTS <br />T <br />m <br />D <br />D <br />D <br />m <br />m <br />N <br />ED <br />'017 <br />U" <br />4L <br />/ED <br />017 <br />HEALTH <br />Area Im Employee ID#'�Qv�J <br />SPE IAL Well Permit <br />WAIVER Received <br />Constructed Well Depth ft <br />PE <br />Codes <br />SC <br />Info <br />Received <br />B <br />ec Amount <br />Remitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # <br />Well 1D# <br />° <br />2S7d g . `' <br />III 17 <br />&RQO7CvS 3 <br />Wi OONS6 <br />EHD 43-06 WELL /PUMP PERMIT <br />8104/08 <br />