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^ WELL/PUMP PERMIT <br /> `v SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)466-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> rn <br /> JOa ADDRESS 9RPR South Priest Rd_ Cm/21P. French Camp CA 95231 > <br /> CROSS STREET French Camp Rd. APN 193_990-16 PARCEL$IZEZ✓ LANG USE APPLICATION# n°o� <br /> OWNER NAME Kosalakad Corporation PHONE 510-417-0701 <br /> 6• OWNER ADDRESS 40174 Surly Ct CITvrsTATE21PfrpgC^tint, rA 04533 <br /> CONTRACTOR Martell Water Systems Inc. PHONE 995-432-428 <br /> CONTRACTOR AOOREss 1818 Loveridge Rd. CITdSTATa21F PiNshi,q CA 94565 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR AOORESS QTYISTATE21P <br /> LICENSE `L C-57 L C-61 J 0.05 _Ote! NUMBER 510952 EXPIRATION DATE 5/31/2017 <br /> GEOGRAPHICAL INFORMATION: Coordinates% Y Township_ Range_ Section_ <br /> INIENDEDUSE YDOmesticiPrivate J INIgaBorNAgriollNral L Indusb101 L Water QualityM011llodng L SORSamplinglCharacterizaBon <br /> Public Water System <br /> IIdit.mf mo. VfttvSNrnNun. a mor oro um <br /> TYPeOFWORK _New Well _ Replacement Well L Well AteratioNMGdficadon LOther <br /> _Monitoring WNI(s) Of nails LSoll Bodng(s) Yaf eoares LGeotechnical #Meonnpe <br /> _OuI-IN-Service Web L Out-Of-Service Well Renewal L Cross-Connection Repair <br /> New Pump Pump Replacement I Pump Repair I Raise We11 Casin <br /> WELLCONSTRUCTION <br /> Drilling Method-/Mud Rotary Air Rotary Auger I Cable Tool I Push Point I Other <br /> Proposed Well Depth 30n R Expvatian 10„ in diameter J Open OoRam J Gravel PaWGmVsI Size in diameter <br /> Conductor Casing 9n„ indiameter I Conductor Casing Dept R <br /> Well Casing Diameter 5 in ThicknesslGaugeIASTM Schell 95 J Steel L/PRStiC L Stainless Steel L Other <br /> Grout Seal Dept 700 R I Neat Cement(941b bag/540 gat water) r/Sand Cement 1n3 sack mlxO gal water <br /> _Bentonite(20%Solids) L Other <br /> Grout Placement Method brPumped JFree Fall JOther JRelalant/Accelxator(name) NN�� <br /> BINSTAL Installed By Dnller L Pump Contractor Ota InVOIN�b <br /> Concrete Pedestal Dlmensionr.YVidM c R Length– If Thick in Christy Box !Stave Pips <br /> PUMP _SubmersibleL Turbine L Other HP <br /> _.%_ Pump Set R Stalling Water Level T}Iflrl R <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. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE 15 <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL P4 <br /> WORKERS COMPENSATION LAWS. RFS, <br /> M,/I1N�I7MUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 /� FNtCO <br /> SIGNED /e`rL, H'14C- TITLE Estimator DATE 0.ri/7H/2015 N /� <br /> Q �0/J <br /> %1111Z. It , L 1EALTH. <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date r Area_ Employee IGDIN <br /> Grout Inspection By Dale O t 7 SPECIAL WeII Permit <br /> Pump Inspection By- Data C WAIVER Received <br /> Soil Boring In so Date rstructed Well Depth It <br /> COMM TS D M 1 fLM1.L T <br /> PE SC Received CheckG Amount Date PermiU Invoke# WeII ID# <br /> Codes Info B Cash Remitted Service"R nest# <br /> 3c, 7B �Q; UOZeis ROOgasaz <br /> L — <br /> EHDaz{0 wELLf`U.P.LAT <br /> rwn2 <br />