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#5009 WELL J PUMP PERMIT <br />SAN JOAQUIN COL Nn ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER Avg 3a" PL- STOOCTON CA 94482 - (2N) 469.3420 <br />NON-Ruu.sDABLE PERMIT CALL (209)..953-7697 FOR INSP£(.7TIU\S EXPIRES i YEAR FROM DATE ISSUED <br />JONADDRESs 9422 Priest Road caymp French Camp 95231 <br />ICROSSSzRgtr French Camp Raad APN 193-220-72 PARCSLSIuLAND VSEAPPUCATIONIs <br />OWNER NAME Ed & Debbie Camera PnoNE 234-1414 <br />OWNERADORES.S Same CITYiSTATV7AP <br />CONTRACTOR Delta Stockton Pump PHONE 456-9525 <br />3CONT9A,CTORAm*m bob S. California Street CffvsTATSrrkP Stockton CA 95203 <br />Si18clNiTRAcToR PHONE <br />SUBCONTRACTOR AMRfM CrTYISTATE/Zip <br />LICENSE CC -57 d(c-61 0D-09 001hu ......._.. NUMBER 724778 ExPH1ATtON DATE <br />GEOGRAPHICAL INIPOR.NATION: COOrdiestes X Y Township ­ Raage—__.__. Sectioa <br />NTENOW USE I ticIftvatt 0 ImptilliAgricllmral 0 Industrial 0 Water Quality Monitoring 0 Soil SampJing>CharaCtetiarrriaa <br />0 Pubtic Water Syysmtem <br />Mdiffaraut from Uwnar. m . <br />M <br />a.9 <br />t Tra of WURIC u New wen u RepiwAnwrit Well ❑ Wzli AlwratsoolModificmuon 0 Test Hole 0 tither _. _. <br />0 monitorag Wtt!(s} ti of wills O Soil amr g(s)"gx ❑ Gtotethnital %bf aR <br />o WAn rs.,p,.,,r. — n — —.— .._ _ ._ , . _ .., ., w `.. <br />0 New Pump alamp Replacement 0 PuTo R it 0 Cross on ntcsirat r <br />WELL CoNm`TRermON <br />DrNting mttbod 0 Mud Rosary 0 Air Rorary 0 Auger 0 Cable Tool 0 Push Point 0 Odd <br />Proposed Weil Depth fl Excavation_m diwwwr 0 Open Boum 0 Gr vC1 PSCk I Gravel Sim In distnew <br />0 Conductor Caaing in diameter / cblwucux Casing Depth ft <br />Well Canag Diamtua __ in ThiektaaalC*u&tiASTM Sc#ted _ 0 Steel 0 Plastic 0 Stainitas Steal 0 Other <br />Grout Send Depth --- ft C Neat Cr=t (94 lb bog J S• 10 gal town s) 0 Sand Cement _arc* bliv 17 gal wane <br />0 Bentonite (20Y solids) 0 Manufacrurer Spec % svluis __...._ of Karns 0 Specs on File C Spocs Subrnztitd <br />Grout PlauHceat Methad 0 Pumped 0 Free Pall 0 Other,__ 0 Retardant f Accelerator (Tunis) <br />PEDESTAL filmalled By 0 Drilla 0 Pump Cuntrartor C3 CYther <br />0 Coatra'tt Pedestal Diawnsions. Width........__ ft Length ft Thick .............._....____.. in 0 Christy sox 0 Stove, Pipe <br />Pusan E Submetsible 0 Turbine OOthn HP Pump Set ft S"ir4,wa-L-4l—zQ. It <br />I HERESY CERTIFY THAT 1 HAVE PRXrARED THIS APPLICATION AND THAT THE WORK WILL HE 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 AC'T'IVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />DE PARTMENT�rUgE/O�•NLY <br />App)IeatiDn Acrzprtd By�„ iiate.._.._i.,,:, Ares Employee lIYli <br />Grout Inspection By Dote _, 0 SPECIAL Wtil Permit <br />Pump Inspection By Date %�—ZZ- � .. 0 WAIVER Received <br />Destruction Inspection By Date Construdw Wen Depth tt <br />COMMENTS <br />"4 a sa.ax.twn W ELL PtnaP PE"IT <br />sA,+p <br />