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' 19008 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 <br />GALL ('LU9) 9b3-7697 FOR INSPECTIONS <br />EXPIRES 1 YEAR FROM DATE ISSUED <br />Chec <br />Amount <br />Remitted <br />Date <br />JOB ADDRESS <br />95 01 E. <br />FRENCH CAMP RD, <br />CITY/ZIP MANTP.CA <br />95 :l <br />CROSS STREET_ <br />AUSTIN <br />APN 201-09-010 <br />PARCEL SIZE 5 8. 4 SAND USE APPLICATION # <br />OWNER NAME <br />DEGRAAF <br />t k(_41L, i a Tr <br />L475pj <br />PHONE 909 608 -039-4 <br />OWNER ADDRESS <br />00 1 E. <br />FRENCH <br />CITY/STATE/ZIP <br />MANTF.CA CA 951336 <br />CONTRACTOR <br />Delta Pump-hTnrxmnN <br />ARMAT IRF <br />& MOTOR WORKS <br />WACh. 209-466-9625 <br />CONTRACTOR ADDRESS <br />646 S. <br />California Street <br />CITY/STATE/ZIP <br />Stockton, CA 95203 <br />SUBCONTRACTOR <br />PHONE <br />SUBCONTRACTOR ADDRESS <br />LICENSE 0 C-57 X C-61 <br />❑ D-09 ❑ Other, <br />CITY/STATE/ZIP <br />NUMBER 724778 EXPIRATIONDATE 08/11 <br />GEOGRAPHICAL INFORMATION: Coordinates X Y . Township Rancie Section <br />INTENDED USE 0 Domestic/Private CAgation/Aghcultural ❑ Industrial ❑ Water Quality Monitoring 0 Soil Sampling/Characterization <br />❑ Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />1 YPE OF WORK ❑ New Well 0 Replacement Well 0 Well Alteration/Modification 0 Other <br />u Monitoring Well(s) # of wells 0 Soil Sorin s # of borings # of borings <br />9O ❑ Geotechnical g <br />0 Out -Of -Service Well 0 Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />lew Pump Pump Replacement 0 Pump Repair 0 Raise Well Casina <br />Drilling Method 0 Mud Rotary 0 Air Rotary 0 Auger ❑ Cable Tool 0 Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter 0 Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br />C Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched 0 Steel 0 Plastic O Stainless Steel ❑ Other <br />Grout Seal Depth ft 0 Neat Cement (94 Ib bagl5-10 gal wafer) ❑ Sand Cement sack mix17 gal water <br />C Bentonite (20% solids) ❑ Other <br />Grout Placement Method 0 Pumped ❑ Free Fall O Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By 0 Driller 0 Pump Contractor 0 Other <br />C Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br />PUMP 0 Submersible urbine R Other HP Pump Set ft Standing Water Level 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 COMPENSA'RDAI-U44424 <br />MINI HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br />SIGNED TITLE CE <br />DATE 3/1 /2017 <br />EP RTMENT USE ONLY <br />Application Accepted By Date <br />---s <br />Grout Inspection By I Date <br />Pump Inspection By Date <br />Soil Boring Inspection By Date <br />COMMENTS <br />T <br />m <br />m <br />ID <br />0 <br />0 <br />m <br />m <br />N <br />Area l Employee ID# T".� <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth ft <br />PE <br />Codes <br />SC <br />Info <br />Received <br />B <br />Chec <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Re uest # <br />Invoice # <br />Well ID# <br />�� <br />, JI <br />3 <br />WOW, I <br />8/04/08 WELL /PUMP PERMIT <br />