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774 <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 'I YEAR FROM DATE ISSUED <br /> t Ul <br /> Jos ADDRESS 8809 S.Priest Rd. CITY/ZIP French Camp,95231 I My <br /> M <br /> CROSS STREET French Camp Rd. APN 193-14-017 PARCEL SIZE 0.58 LAND USE APPLICATION m M <br /> M <br /> N <br /> OWNER NAME Leslie Williams Estate (Mike Ruch-Executor) PHONE (509)993-8889 R <br /> OWNER ADDRESS PO Box 408 CITY/STATE/ZIP Tolbert,WA 99005 <br /> CONTRACTOR Delta Pump Inc- PHONE (209 )466-962_5 <br /> CONTRACTOR ADDRESS 646 S. California St CITY/STATE/ZIP Stockton, CA 95203 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ❑ C-57 CXC-61 �' D-09 ❑ Other NUMBER 1055434 EXPIRATION DATE_8/16/2 0 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE Domestic/Private u Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> ❑ Public Water System <br /> If different from Owner: VV5iFr 5ystom Name Contact Name or Phone Number <br /> TYPE OF WORK ❑ Now Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> � <br /> Monitoring Wellof borings s) ;;of wells C Soil 6oring(s) C oirblirft <br /> Geotechnical �' <br /> Out-Of-Service Well C Out-Of-Service Well Renewal ❑ Cross-Connection Repair AI O <br /> New Pump Pump Replacement ❑ Pump Reoair ❑ Raise Well Casing <br /> WELL CONSTRUCTION SA <br /> 4Q 9 <br /> Drilling Method C Mud Rotary ❑Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other E 111 Q <br /> Proposed Well Depth It Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size 4�dlq TY <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft RjM� T <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel C Other <br /> Grout Seal Depth ft C Neat Cement(94 Ib ba9/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br /> 1 Bentonite(20%solids) ❑ Other <br /> Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br /> C Concrete Pedestal Dimensions:Width ft Length It Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP XSubmersiblo73 Turbine ❑ Other HP 1_5 Pump Set 85 ft Standing Water Level 26 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 COMIJENUZON LAWS. <br /> �"�11124' HOUPR DVANCE NOTICE I.EQUlRErJ '--OR INSPECT IONS <br /> SIGNED14W TITLE CEO DATE 06/25/2020 <br /> s <br /> 1' 1W IrUJ, 11 •tni°c•1•� �r}- .' <br /> 1 a � <br /> • .0tet'• t <br /> PUMP/WEL is located near the north v <br /> corner of house&carport/deck f • �. <br /> yam' DEPARTMENT USE ONLY <br /> Application Accepted By C— Z_ Z_ Date I✓ o Area �(1 Employee IDI/ <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By-_i LA [ 5 ILQ (9LSt � Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received hoc Amount Permit! <br /> Codes Info a Date ash Remitted Service Re uest# Invoice# Well ID# <br /> X13 ) os� 1/2�� $77 <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 8/04108 <br />