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i <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> W <br /> JOB ADDRESS 677 E. DUDLEY RDy^ /� h7CITY/zIP FRENCH CAMP 95231 a <br /> CROSSSTREET FRENCH CAMP RD APN I / I —060-01'PARCEL SIZ��AND USE APPLICATION# <br /> OWNER NAME DON MOUNT PHONE 209.601.4256 <br /> OWNER ADDRESS 677 E. DUDLEY RD. CITY/STATE/zlP FRENCH CAMP, CA. 95231 <br /> CONTRACTOR N IS,S IRRIGATION, INC PHONE 209.599.3456 <br /> CONTRACTOR ADDRESS 215W. MAIN STREET CITY/STATE/zIP RIPON, CA, 95366 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATEIZIP <br /> LICENSE C-57 C-61 D-09 XOther C10 NUMBER 662732 EXPIRATION DATE 01/31/19 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br /> INTENDED USE Domestic/Pnvate i Irrigation/Agricultural i i Industrial i Water Quality Monitoring i Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water SySterr,Name one a"or Phone Number <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells Soil Boring #of borings #of boringss) i.Geotechnical � T <br /> Out-Of-Service Well i Out-Of-Service Well Renewal i Cross-Connection Repair <br /> New Pump X Pump Replacement I Pump Repair i Raise Well Casing <br /> n I D <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other ll a y 2418 <br /> Proposed Well Depth ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size_ Ski jjVter <br /> Conductor Casing in diameter / Conductor Casing Depth ft H E��v/RO `OU, <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched i Steel i Plastic i Stainless Steel i Other EN7k •7 <br /> Grout Seal Depth ft Neat Cement(94 Ib bag/5-10 gal water) Sand Cement sack mix/7 gal T <br /> Bentonite(20%solids) Other JWEMT <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 It Thick in Christy Box i Stove Pipe <br /> PUMP XSubmersible. Turbine Other HP__2 — Pump Set 6f 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 /> JOnRKERS <br /> NTY DINANCES, STATE LAWS, D RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CD AC E WIT T E CALIFOR CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WMPE A N A <br /> I U 2 O V E NOTICE REQUIRED FOR INSPECTIONS--PLEASE CALL(209)953-7697 <br /> SIGNED TITLE M• rQ ,Al— �wy` - DATE <br /> N <br /> E <br /> S <br /> PA TMENT US NAY <br /> Application Accepted By <br /> //11A� Date d�� Area 1 / "/ / Employee ID#%I� <br /> Grout Inspection By Date �SPECIAL Well P@rtTllt <br /> Pump Inspection By 4 Date WAIVER R@c@IV@d <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received Chec Amount Date PermlU Invoice# WeIIID# <br /> Co s Info B arh- Remitted �) Service Request# <br /> 4a <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4/30/12 <br />