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4 RECEIVED <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED MAY <br />ADDRESS 654 FRISBEE LN QCITY/ZIP FRENCH CAMP. 95211NN'112( <br />SSSTREET S. MCKINLEY APN �50—7PARCELSIZE is—LAND USE APPLICATION # I <br />IER NAME JACK WOOD PHONE 482.1921 <br />ER ADDRESS 654 FRISBEE LN ! & t �� CITY/STATE/ZIP FRENCH CAMP, CA. 95231 <br />TRACTOR N & S IRRIGATION, INC PHONE 209.599.3456 <br />TRACTORADDRESS 215 W. MAIN STREET CITY/STATE/ZIP RIPON, CA. 95366 <br />:ONTRACTOR PHONE <br />)R ADDRESS CITYISTATE/ZIP <br />C-57 C-61 D-09 XOther C10 NUMBER 662732 EXPIRATIONDATE 01/31/19 <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section <br />NTENDED USE X Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System <br />If different from Owner: Water System Name on a am e or Phone Number <br />TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br />Monitoring Well(s) # of wells Soil Boring(s) 4 o burings Geotechnical #of bonngs <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />New Pump X Pump Replacement Pump Repair Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br />Proposed Well Depth ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size in dl <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br />Grout Seal Depth it Neat Cement (94 lb bag/5-10 gal water) Sand Cement sack mixf7 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method Pumped Free Fall Other Retardant /Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor Other <br />Concrete Pedestal Dimensions: Width ft Length ft Thick in Christy Box ' Stove Pipe <br />PUMP XSubmersible. Turbine Other HP 1 5 Pump Set i0ft 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 />CU N AND ACTI WITH THF�CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />RKER COMPENS TIO L WS <br />M U �/ C TICE REQUIRED FOR INSPECTIONS - P EASE CALL (209) 953--77j697) <br />SIGNED TITLE V l l'./� DATE iCJ� <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Borin nspection By. <br />COMMENTS <br />etu s) <br />11 2018 <br />►I ENTAL IIEALT <br />Ay 14 208 <br />opngRTMAfrk <br />NT <br />EP RTMENT U E O LY <br />r Date — Ir2 �1 <br />p/ <br />Area " / Employee ID#,o4� <br />Date <br />) w 2 <br />SPECIAL WBII PBd <br />Date <br />- WAIVER R8C01Ved <br />Date <br />Cons/ntrructed Well Depth ft <br />PE SC Received P?fjWV Amount Date <br />Codes Info --CTsh Remitted <br />Permit/ Invoice# WellID# <br />Service Request # <br />4311 6 4V 24 ly <br />) w 2 <br />EHD 43-06 <br />4/30/12 <br />WELL /PUMP PERMIT <br />