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17775 y 7 <br /> 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 /> T <br /> JOB ADDRESS n 5 w_ yc-f-t n P r rdCITYlZIP FRENCH CAMP 9 5 2 31 m <br /> D <br /> CROSS STREET FRENCH CAMP RD. APN 193-06-003 PARCEL SIZE <br /> __L3 UND USE APPLICATION# A <br /> M <br /> OWNER NAME LOU SEACHAOcn <br /> PHONE 209-623-8494 <br /> N <br /> OWNER ADDRESS 1 1 7 0 DE VAL CT. CITY/STATE/ZIP STOCKTON CA 95210 <br /> CONTRACTOR _ Delta Pump PHONE 209-466-9625 <br /> CONTRACTOR ADDRESS 646 S. California Street CITY/STATEIZIP Stockton, CA 95203 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ❑ C-57 X C-61 0 D-09 0 Other NUMBER 724778 EXPIRATION DATE_08/3 (0 _ <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE ❑ Domestic/Private CNMgatlon/Agricultural 0 Industrial 0 Water Quality Monitoring 0 Soil Sampling/Characterization <br /> 0 Public Water System <br /> If different from Owner: Water System Name UontactName or Phone Number <br /> TYPE OF WORK 0 New Well 0 Replacement Well 0 Well Alteratlon/Modification 0 Other <br /> 0 Monitoring Well(s) #of wells 0 Soil Boring(s) #of borings 0 Geotechnical #of borings <br /> 0 Out-Of-Service Well 0 Out-Of-Service Well Renewal 0 Cross-Connection Repair p Y <br /> 0 New Pum Pum Replacement 0 Pum Repair 0 Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method 0 Mud Rotary 0 Air Rotary 0 Auger ❑ Cable Tool 0 Push Point 0 Other .SiC�p <br /> Proposed Well Depth ft Excavation in diameter 0 Open Bottom 0 Gravel Pack/Grave' A��IjZ�fJ' Teter <br /> ❑ Conductor Casing In diameter / Conductor Casing Depth ft H �w c1 <br /> Well Casing Diameter_, In Thickness/Gauge/ASTM Sched 0 Steel ❑ Plastic 0 Stainless Steei `ro r <br /> Grout Seal Depthft 0 Neat Cement(94 Ib ba916-10 gal water) ❑ Sand Cement sa� 17 gal water <br /> 0 Bentonite(20%solids) 0 Other <br /> Grout Placement Method 0 Pumped 0 Free Fall 0 Other 0 Retardant/Accelerator(name) <br /> PEDESTAL Installed By 0 Driller 0 Pump Contractor 0 Other <br /> ❑ Concrete Pedestal Dimensions:Width ft Length ft Thick In 0 Christy Box 0 Stove Pipe <br /> PUMP ubmersible0 Turbine O 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 /> CURREN r AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT.[ AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIM M 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECT O{ $ A <br /> SIGNET `KtNLH AiMV tU. r <br /> Mai- <br /> {{ <br /> ro <br /> i-- PLOWED LAND <br /> MANTHEY RD. <br /> PUMP/WELL is located under a <br /> _AL <br /> bunch of trees aprox.205.85 ft. <br /> from the edge of Yettner Rd. • <br /> A-1 Ell :, <br /> D <br /> DIRT Rd./Track <br /> iH <br /> �.` • o e 'm <br /> o <br /> qtrDEPARTMENT USE ONLY <br /> Application Accepted By/ / �� Date. "L� t <br /> - Area All L` Employee 1D#k t -gL' � <br /> Groyt Inspection By Data SPECIAL Well Permit <br /> Pump Inspection B Date WAIVER Received <br /> Soil Boringl�atlon By Date Constructed Well Depth ft <br /> COMMENYS 717 <br /> PE SC Received Check#/ Amount Permit/ <br /> Codes Info B Cash Remitted Date Service Request# Invoice# Well ID# <br /> ozr�y�� �IIZI5 5,2 C0-7/:;5;0(r,C, 003 3 <br /> EHD 43.06 <br /> 8/04/08 WELL/PUMP PERMIT <br />