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w:+a <br /> 18323 <br /> WELL/PUMP PERMIT <br /> A JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205.6232 - (209)468.3420, <br /> DN-REFUNDABLE PERMIT CALL 209 953.7697 FOR INSPECTIONS EXPIRES 'I YEAR FROM DATE ISSUED <br /> B ADDRESS $372 GROVE TREE RD. CITY/ZwFRENCH CAMP 95231 m <br /> SSFF � <br /> :OSB STREET MATHEWS APN tq 3IR aD� FARDEL SIZE 10"1TND USE APPLICATION# m <br /> VNER NAME DEAN KOMURE - PHONE 482_8485 " <br /> VNER ADDRESS P.O. BOX 155 CITY/STATE/ZIP FRENCH CAMP CA 95231 <br /> )NTRACTOR . Delta Pump—,'TCC Hg]nN Ag MA TTIJRE P Mo Top WORKS ET;N t. 209-466-9625 <br /> INTRACTORAODRESS 646 S. California Street CITYISTATEIZIP Stockton, CA 95203 <br /> 'BCONTRAOTOR PHONE <br /> -BCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> TENSE D 0-57 N C-61 ❑ D-09 ❑ Other NUMBER 724778 EXPIRATION DATE 08/11 <br /> :OGRAPHICAL INFORMATION: Coordinates X Y Township— Range_ Section_ <br /> rENOED USE ❑ Domestic/Private XNrrlgatlon/Agrlcultural ❑ Industrial ❑ Water Quality Monitoring D Soil Sampling/Characterization <br /> ❑ Public Water System <br /> If dlfferenifrom Owner: Contact Name or Fhone Number <br /> 'PE OF WORK 0 New Well ❑ Replacement Well ❑ Well Alteration/Modification 0 Other <br /> ❑ Monitoring Well(s) #of wells 0 Soil Boring(s) 0 o borings O Geotechnical ik of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> ❑ New Pump QMmpReplacement ❑ Pump Repair ❑ Raise Well Casing <br /> ELL CONSTRUCTION <br /> Illing Method ❑ Mud Rotary 0 Alr Rotary ❑ Auger 0 Cable Tool D Push Point ❑ Other <br /> oposed Well Depth ft Excavation In diameter O Open Bottom ❑ Gravel Pack/Gravel SIZE, In diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter r_ In Thickness/Gauge/ASTM Soiled ❑ Steel ❑ Plastic D Stainless Steel ❑ Other <br /> Grout Seal Depth ft ❑ Neat.Cement(94 Ib bag/5.10 gal wafer) 0 Sand Cement sack mix17 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> ,out Placement Method 0 Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> :DESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal Dimensions:Width it Length ftThick In ❑ Christy Box ❑ Stove Pipe <br /> IMP tOubmerslbleD Turbine ❑ Other HP S Pump Set 85 ft StandlrIerLev at 28 ft <br /> HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> )AQUIN COUNTY ORDINANCES,-STATE LAWS, AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE 15 <br /> JRRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS 81-ATE LICENSE BOARD AND THATA AM IN COMPLIANCE WITH ALL <br /> ORKERS COMPENSATIO AWS, <br /> UIININIUIVI 4 110t)R ADVANCE NOTICE REQUIRE!:3 FOR INSPECTIONS <br /> GNED TITLE CEO DATE 7-7-2016 <br /> a }t C Q/�I <br /> IT �� <br /> WA4 <br /> PUMP/WELL IS LOCATED <br /> APPROX 279.55 FT w rMF <br /> FROM THE ROAD '1 <br /> ,: r �FiVFO <br /> x , Z <br /> DEPARTMENT USE/ ONLY <br /> tTppllcation Aeospted By /�-K.- Daie '��r-f�l l� <br /> Area U Employee ID#1e5r.o <br /> Grout Inspection ByDale SPECIAL Well Permit <br /> Pump Inspectlon Sy Ah{EPn'1 A Date 6-/SI I q WAIVER Received <br /> Sell Boring Inspection By Date Constructed Well Depth ft <br /> OMMENTS <br /> PE SC ReceivedAmount Date Permit/Info B heck Remitted Service Request# Invoice# Well M#4Ss� a G z7 3 5_3 a -11- 6 S(>,0�?S��! W V0030 I <br /> iD 43.00 <br /> D4108 WELL/PUMP PERMIT <br />