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a WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-8420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> rrl <br /> JOB ADDRESS 9698 South Priest Rd Cm/ZiPP``'') French Camp, CA 95231 <br /> CROSS STREET French Camp Rd. APN_1Q3_���_95 PARCELSIZE ` '• LAND USE APPLICATION# a <br /> OWNER NAME Xusalakad Corporation PHONE 510-417-0701 �^ <br /> t' OWNER ADDRESS _40174 S Sa Ct CITYISTATEIZIP Fr r'fl <br /> p--dy ee ant,C9 44538 <br /> CONTRACTOR Martell Water Systems, Inc. PHONE 925-432-4282 <br /> CONTRACTOR ADDREss 1818 Loveridge Rd. CITYISTATEIZJP Plttshucq CA 4456 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATElL p <br /> LICENSE 4(C-57 L C-61 -j D-09 _ Other NUMBER 51 09522 EXPIRATION DATE 5/31_L2017 I <br /> GeoGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br /> INTENDED USE Y DomesticlPnvate J InigatiOn/Agncultural L Industrial L Water Quality Monitoring L Soil Sampling/Characterization <br /> Public Water System <br /> If mffemnt tram Owner wat.,syva — C°r.t=Name or ne um°e; <br /> TYPE OF WORK -/New Well _Replacement Well L Well Alteration/Modification L Other <br /> _Monitoring Well($) of wells L Soil Boring(s) p°too nCs L Geotechnical <br /> _Out-Of-Service Well L Out-Of-Service Well Renewal L Cross-Connection Repair <br /> New Pump Puma Replacement I Pump Repair i Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method VMud Rotary Air Rotary Auger I Cable Toot Push Point I Other <br /> Proposed Well Depth Ino It Excavation 10" in diameter -jOpen Bottom J Gravel PaWGravel Size in diameter <br /> `�ContluUor Casing 1n„ in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_52 in Thickness/Gauge/ASTM Schad 950 J Steel L/Plastic L Stainless Steel L Other <br /> Grout Seal Depth 7(18 it I Neat Cement(94/b bag/5.10 gal water) /Sand Cement 1(1 3 sack mixl7 gat water <br /> _Bentonite(20%solids) L Other 1 <br /> Grout Placement Method VPumped J Free Fall J Other J Retardant I Accelerator(name) i <br /> rA Installed By Duller L Pump Contractor - Other i <br /> Concrete Pedestal Dimensions:WidU-- _ft Length ft Thirst in Christy Box I Stove Pipe '��, �10 <br /> ilk <br /> PUMP _SubmersibleL Turbine L Other HP Pump Set ft Standing Water Level_'1"fifl� ft +) <br /> 1 HEREBY CE:2TIFY 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 p�AyM <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 24 HOUR ADVANCE <br /> �NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED_ oma`{- TITLE Estimator DATE 05/28/901 S 'J 9 <br /> ( I I I I I A <br /> 11 IN J, i-4 nC <br /> I I I <br /> i <br /> I I I <br /> i I I I <br /> DEPARTMENT USEONLY <br /> _ <br /> Application Accepted By A"' Date f Area D Employee ID#�—==�"v" <br /> Grout Inspection By + �yP.-Date &&& SPECIAL Well Per'rttit <br /> Pump Inspection BDate C WAIVER Received <br /> Soil Boring Ins 'on B. Date C nstructed Well Depth ft <br /> COMM 7S SZr..� <br /> PE SC Received Chock#/ Amount Data Pertmt! nvoic�# Well Ib# <br /> Codes Info B Cash Remitted Service Re uest# <br /> e200 2 <br /> EHD 4 <br /> WELL JPUMP PERMIT <br /> 4/30lt2 <br />