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20697 WELL/PUMP PERMIT J <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205-6232 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 255 E. FRENCH CAMP RD. CITr/zIP FRENCH CAMP CA 95231 m <br /> CROSS STREET ASH ST. APN 193-10-014� PARCEL SIZE 0 . 13 LAND USE APPLICATION# cy <br /> OWNER NAME TONY NOCETI E�. t.E� -�% �L� C�5fi LiZ�I PHONE4 8 2-6 9 6 9 <br /> OWNER ADDRESS P-0. BOX _; 4M FRENCH CAMP CITY/STATE/ZIP FRENCH CAMP CA 95231 <br /> CONTRACTOR Delta Pump-STOCXTON ARMATURE & MOTOR WORKS ff"Q. 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 C-57 X C-61 ❑ D-09 ❑ Other NUMBER 724778 EXPIRATION DATE 08/1� <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE 'bomestic/Private 0 Irrigation/Agricultural ❑ Industrial 0 Water Quality Monitoring 0 Soil Sampling/Characterization <br /> 0 Public Water System <br /> If different from Owner: a er ystem Name Contact Name or Phone Number <br /> TYPE OF WORK 0 New Well ❑ Replacement Well 0 Well Alteration/Modification 0 Other <br /> 0 MonitoringWell(s) #of wells ❑ SoilBoring(s) #of borings ❑ Geotechnical #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> 0 New Pum mp Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method 0 Mud Rotary ❑Air Rotary ❑ Auger ❑ Cable Tool 0 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 0 Steel 11Plastic 0 Stainless Steel 0 Other <br /> Grout Seal Depth ft ❑ Neat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix17 gal water <br /> 0 Bentonite(20%solids) ❑ Other <br /> Grout Placement Method ❑ Pumped 0 Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By 0 Driller ❑ Pump Contractor 0 Other <br /> ❑ Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP XVubmersibleD Turbine 0 Other — H P Pump Set--,q-l_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. 1 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 /> MINIMU 4 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED_ TITLE CEO <br /> DATE <br /> PUMP/WELL IS LOCATED AT THE BACK <br /> OF THE STORE SEE INSERT <br /> N al- <br /> - i f I I I JO <br /> P A T M E N T USE O N LY ENVIRONMENTAL <br /> HEALTH DEPART <br /> Application Accepted By Date l Area Employee ID# <br /> Grout Inspection ByDate SPECIAL Well Permit <br /> Pump Inspection By Date 0 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received 9 he Amount DatPermit/ <br /> Codes Info B e Cash Remitted Service Re uest# Invoice# Well ID# <br /> Ix <br /> 3(43'5 a�2ilr�• <br /> EHD 43.06 <br /> 8/04/08 WELL/PUMP PERMIT <br />