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Kit-6tIVtU <br /> OCT 3 0 2017' <br /> • ,19929 WELL/PUMP PERMIT FF((�� , T �e'TM <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelfdti FFl��''5205-6232 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS TYEAR FROM DATE ISSUED <br /> ft,/ 1 <br /> JOB ADDRESS CITY/ZIP FRENCH CAMP 9-52:31 m <br /> 11 v <br /> CROSS STREET MATTHEWS APN 4-3'1-2 7-011 PARCEL SIZE 2. 6 2LAND USE APPLICATION# <br /> OWNER NAME ROBERT K f LLSON A rift Q PHONE 9 9 3-3 91 5 N <br /> / 23 I <br /> OWNERADDRESS 2$165 S. CHRISMAN RD. �Ig�4 S r�k/n)_0 C41Y/STATE/ZIP TRACY CA 95231 2 31 <br /> CONTRACTOR Delta Pump_$q ]CKTnN 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 0 C-57 X C-61 ❑ D-09 ❑ Other NUMBER 724778 EXPIRATION DATE 08/11 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE (XRomestic/Private ❑ Irrigation/Agricultural 0 Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> 0 Public Water System <br /> If different from Owner. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> 0 Monitoring Well(s) #of wells 0 Soil Boring(s) #of borings ❑ Geotechnical #of borings R N <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair FCF� <br /> ❑ New Pump ❑ Pump Replacement )Q)flump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION S�4h,JOAI <br /> Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other H 6wb, '. co. <br /> awl 4.1 <br /> Proposed Well Depth ft Excavation in diameter ❑ Open Bottom 0 Gravel Pack/Gravel Size in tli t <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched 0 Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth ft ❑ Neat Cement(94 ib bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br /> 0 Bentonite(20%solids) ❑ Other <br /> Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) ' <br /> PEDESTAL Installed By 0 Driller ❑ Pump Contractor 0 Other <br /> 0 Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP Submersible❑ Turbine ❑ Other HP—2 Pump Set 61 ft Standing Water Level 21 ft <br /> 1 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 CALIF NIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> O r— �O -j Z )N LAWS. <br /> d MINIMU 4 HOUR VANCE NOTICE REQUIRED FOR INSPECTIONS <br /> CD Ln <br /> CD <br /> m m ITLE CEO DATE1 0/25/2017 <br /> O Z = <br /> = G1 O 2 <br /> rD m G <br /> � N <br /> D v This house <br /> m <br /> = Z <br /> DD <br /> p 1 4 <br /> O O I <br /> Z -a G) <br /> C m <br /> r Z . d1 <br /> to /iL�e <br /> M to <br /> C m <br /> K O WELL Is located approx.13.6 ft <br /> U -n :3 <br /> v Z from the side of the house. <br /> 0. <br /> C ' , <br /> O m <br /> C 70 <br /> i <br /> DEPARTMENT USE ONLY <br /> WApplication Accepted By / 1i Date S/ Area I �7 Employee 09�t rl� <br /> Grout Inspection By yy Date SPECIAL Well Permit <br /> Pump Inspection By X : Date ( WAIVER Received <br /> Soil Boring In, pection By Date Constructed Well Depth I ft <br /> COMMENTS T i.� C' C01 (G1L.C i.LI.o., j, c� T i V1J <br /> PE Received Che Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Remitted Service Request# <br /> I S s 0s0 <br /> EHD 43-06 <br /> 8/04/08 WELL/PUMP PERMIT <br />