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20960 <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 /> JOB ADDRESS 9362 McKinley Ave CITY21P French Camp 95231 m <br /> D <br /> CROSS STREET_E. Wyman Rdo <br /> aPN 1 93-14-026 PARCEL SIZE n .2 QLAND USE APPLICATION# C7 <br /> OWNER NAME Robert Shelton ,� ���� �� PHONE209-470-4701 <br /> OWNER ADDRESS SAME CITY/STATE/ZIP <br /> CONTRACTOR Delta Pump RTnCxmnis ARMATrtRF !Z MOTOR WORKS MIR. 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 . D C-57 XC-61 ❑ D-09 ❑ Other NUMBER 724778 ExPiRATIONDATE 08/1 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE Cl Domestic/Private 0 Irrigation/Agricultural 0 Industrial 0 Water Quality Monitoring 0 Soil Sampling/Characterization <br /> ❑ Public Water System <br /> If different from Owner. a er ys em ame Contact Name or Phone Number <br /> TYPE OF WORK 0 New Well 0 Replacement Well 0 Well Alteration/Modification ❑ Other <br /> 0 Monitoring Well(s) #of Wells 0 Soil Boring(s) #of borings �C <br /> ❑ Geotechnical N <br /> 0 Out-Of-Service Well 0 Out-Of-Service Well Renewal 0 Cross-Connection Repair jj <br /> ❑ New Pump 0 Pump Replacement �; Pump Repair 0 Raise Well CasingV <br /> WELL CONSTRUCTION �p <br /> Drilling Method 0 Mud Rotary 0 Air Rotary 0 Auger 0 Cable Tool 0 Push Point 0 Other SAAf <br /> Proposed Well Depth ft Excavation in diameter 0 Open Bottom ❑ Gravel Pack/Gr gl �/N' n diameter <br /> 0 Conductor Casing in diameter / Conductor Casing Depth ft ITh DI-- of <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched 0 Steel 0 Plastic 0 Stainless Steel ❑ Other`Q 11"It _ <br /> Grout Seal Depth ft ❑ Neat Cement(94 lb bag/5-10 gal water) 0 Sand Cement sack mix17 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 ❑ Other <br /> ❑ Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP X.i Submersible❑ Turbine 0 Other HPC_ 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 /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> M4NIMUP 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED y TITLE CEO DATE 1_/10/2019 <br /> Aprox 59 It <br /> from E + <br /> f Wvman Rd +- <br /> �� <br /> _ , I un'Q <br /> i <br /> 77-71. <br /> HEALTH <br /> NT <br /> Application Accepted By uo�Date Area <br /> _�+ff <br /> Employee ID#AB1;CV <br /> Grout Inspection By Date *SPECIAL Well Permit <br /> Pump Inspection By Date_`01( G 1 I 1 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Amount Permit/ <br /> Codes Info B Cash Remitted Date Service Re uest# Invoice# Well ID# <br /> ,3/7G <br /> EHO 43-06 <br /> 8104/08 WELL/PUMP PERMIT <br />