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Tnihdl ScQn 5��y�►� Vvi ,,� /r 2-5 <br /> TO <br /> . . , <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTALHEALTIDEPARTMENT 1868 EAST HAZELToN AVENUE-SWCKTON CA 96205-(209)458-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 7 YEAR FROM DATE ISSUED <br /> N <br /> JOB ADDRESS 17685 S.AUSTIN RD. car/ZIP MANTECA,95336 ;A <br /> /fe / n <br /> CROSSSTREET HWY 120 APN��^�'/ % CII IC PARCELS6 0—e'LAND BE APPLICATION# O <br /> �i <br /> OWNER NAME KEITH STEWART PHONE 456.2293 <br /> OWNER ADDRESS 17685 S.AUSTIN RD. CmiSTATE/ZIP MANTECA,CA.95336 <br /> CONTRACTOR N&S IRRIGATION, INC PHONE 209.599.3456 <br /> CONTRACTOR ADDRESS 215 W MAIN STREET cITYSTATE21P RIPON CA, 95366 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STAWZP <br /> LICENSE �C-57 II C-61 J D-09 XOmer Ci10 NUMBER 662732 EXPIRATION DATE 01/31/17 <br /> GEOGRAPHICAL INFORMATION: Coordinates Y Township_ Range_ Section_ <br /> INTENDED UsE XDomesticPnvale J Irrigation/Agricultural S industrial ❑Water Oualiy Monitoring O Soil Sampling/Characlerizaaon <br /> Public Water System <br /> lieutenant Nom Owner: eery em ame ams or one um r <br /> TYPE OF WORK _ New Well - Replacement Well ❑Well Alteration/Modification Other <br /> Monitoring Wells) #otwells Soil Bonng(s) 0.1 1Geotechnical °a1°atlma <br /> Out-O"ervice Well Out-Of-Service Well Renews Crass-Connection Repair <br /> New Pump X Pump Replacement Pump Repair Raise Well Casino <br /> WELL CONSTRUCTION <br /> Drilling Method - Mud Rotary Air Rotary Auger Cable Tool n Push Point I Other <br /> Proposed Well Depth ft Excavation in diameter J Open Bottom Gravel Pack/Gravel Size In diameter <br /> _ Conductor Casing_in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thiclmess/Gauge/ASTM Sched 1 Steel Plastic :I Stainless Steel f I Other <br /> Grout Seal Depth ft Neat Cement(94 Ib bag/5-10 gal water) Sand Cement sack mixR gal water <br /> _ <br /> Bentonite(20%solids) Other <br /> Grout Placement Manod O Pumped 7 Free Fall DOther -,.Retardant/Accelerator(name) <br /> PEDESTAL Installed By L Driller a Pump Contractor Other <br /> - Concrete Pedestal-Dimensions:Width it Length it Thick in Christy BOX _i Slove Pipe <br /> PUMP XSUbmer51bl9C Turbine 0 Other HP 1 Pump Set 40 ft Standing Water Level 24 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 COMPENSATION LAWS. <br /> MINI 4 HO R ADV CE TICE R UIRED FOR ECTIONS-PLEASE CALL(209)953-7-76/9(7�.��(//j�am/a <br /> SIGNED TI eA-�.• DATE Zs' _LZ <br /> N <br /> VV <br /> E <br /> S CEIVED <br /> EB 2 6 2016 <br /> Ef NMENTgI H <br /> IT/ pWCESLTH <br /> RECFn'�D <br /> s /tea <br /> oMf W <br /> DEPARTME T USE//O ONLY `'��C'n � ^Q't <br /> Application Accepted Data b Area Employee lD#yr �n /6:l5 <br /> Grout I I By Date LI SPECIAL WeII Permit <br /> Pump Inspection By Date .. WAIVER Received <br /> Soil BonnB ins cti By Date Co}��^}fletl Well Dap R <br /> COMMENTS l4D//I� 0 RCu.3J�7 dr Yeo OTIC LIS�F'1C. �-Q//e�CB'Ww1 w/ <br /> 14F <br /> PE SC I Received Cheek#/ Amount Date permlM Invoice# Well ID# <br /> Coders Info B Remitted Service Request# <br /> a r <br /> 4'4W747% <br /> EH043L6 W£LLIPUMPPERMIT <br /> anwl2 <br />