Laserfiche WebLink
19109 WELL/PUMP PERMIT <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 941 DUDLEY RD. CITY/ZIP FRENCH CAMP 95231 v <br /> 0 <br /> CROSS STREET FRENCH CAMP ROAD APN 177-()6-022 PARCEL SIZE 4 . 9 LAND USE APPLICATION# M <br /> m <br /> OWNER NAME SHAYNE RIVERS J1 S,60 PHONE510-303 9038 <br /> OWNERADDRESS SAME I e V(iYV �+, CITY/STATEIZIP i <br /> CONTRACTOR Delta Pump-.TnC'KTON ARMATURE & MOTOR WORKS XQ. 209-466-h25 <br /> CONTRACTOR ADDRESS 646 S. California Street CITY/STATE/ZIP Stockton, CA 95203 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE 0 C-57 XC-61 ❑ D-09 ❑ Other NUMBER 724778 EXPIRATIONDATE 08/I1 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE XlXlomestic/Private 0 Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> 0 Public Water System <br /> If different from Owner: Water System Name Uontact Name or Phone Number <br /> TYPE OF WORK ❑ New Well 0 Replacement Well 0 Well Alteration/Modification ❑ Other <br /> 0 Monitoring Welf(s) #of wells O Soil Boring(s) #of borings ❑ Geotechnical #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal 0 Cross-Connection Repair <br /> C New Pump EVAmp Replacement 0 Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger C Cable Tool C Push Point 0 Other <br /> Proposed Well Depth ft Excavation in diameter ❑ Open Bottom 0 Gravel Pack/Gravel Size in diameter <br /> 0 Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched 0 Steel 0 Plastic 0 Stainless Steel 0 Other <br /> Grout Seal Depth ft C Neat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br /> 0 Bentonite(20%solids) 0 Other <br /> Grout Placement Method ❑ Pumped 0 Free Fall 0 Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By 0 Driller ❑ Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal Dimensions:Width ft Length ft Thick in 0 Christy Box ❑ Stove Pipe <br /> PUMP XXubmersible❑ Turbine 0 Other HP 3 Pump Set 10 1 ft Standing Water Level 35 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 COMPENSATIO <br /> INIMUM 4 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED TITLE CEO DATE 1 -1 8-2 01 7 <br /> V <br /> PUMP/WELL Is located approx. <br /> 452 ft.from the road along the <br /> fence line. <br /> mEv <br /> 7A <br /> 1 4 HEALTH <br /> P T CES <br /> ,w <br /> C <br /> E�'ARTMENT USE ONLY �VIRONMENTN. <br /> HMTH DIE <br /> NT <br /> Application Accepted By..__ Date � 1 Area Employee ID# Vw <br /> Grout Inspection By Date SPE IAL Well Permit <br /> Pump Inspection By aul1 Date O *Its WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received C Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Cash Remitted Service Request# <br /> WpbD3°I2-�� <br /> EHD 43.06 <br /> 8/04/08 WELL/PUMP PERMIT <br />