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Tnihdl Scan Sl�ili� ���b zyz—25y <br /> Jr 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 <br /> N <br /> JOB ADDRESS 17685 S.AUSTIN RD. CITY/ZIP MANTECA,95336 m <br /> CROSS STREET HWY 120 APN �:1 1 PARCEL SIZE-'" LAND USE APPLICATION# m <br /> rn <br /> OWNER NAME KEITH STEWART PHONE 456.2293 y <br /> OWNER ADDRESS 17685 S.AUSTIN RD. CITY/STATEIZIP MANTECA,CA.95336 <br /> CONTRACTOR N &S IRRIGATION, INC PHONE 209.599.3456 <br /> CONTRACTOR ADDRESS 215 W MAIN STREET CITY/STATE/ZIP RIPON CA- 95366 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATE/ZIP <br /> LICENSE C-57 I C-61 D-09 XOther C10 NUMBER 662732 EXPIRATION DATE 01/31/17 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br /> INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner Water System Name Contact Name or Fri.n.rl.nnoe, <br /> TYPE OF WORK New Well Replacement Well -.Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells Soil Bonng(s) 9 of borings Geotechnical #of borings <br /> Out-Of-Service`r!ell Out-Of-Se,rce Well Ronewa: Crass-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 diameter <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 ft I Neat Cement(94 Ib bag/5-10 gal water) Sand Cement sack mix/7 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 It Length It Thick in Christy Box Stove Pipe <br /> PUMP XSubmersible! Turbine i Other HP 1 Pump Set 40 It Standing Water Level 24 It <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 /> MIN/IIyI�'} 24 HO R ADV CE TICE R UIRED FOR ECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED / TIT well— DATE <br /> N <br /> E <br /> S c�r��® <br /> ops <br /> F2rr�it rrfa NMENT,qL HEA <br /> H <br /> v,o-k beingLT <br /> SF <br /> P,�yWCES <br /> by E:nk"ronRFCEryEo <br /> Fe p sOft 4 ?01� <br /> DEPARTME T USE ONLY "4VT <br /> ApplicationAccepted By- ./ /�/-: Date Area 1,-j_i Employee ID#fir <br /> Grout I eGion By Date SPECIAL Well Permit <br /> Pump Inspection By Date - WAIVER Received <br /> Soil Boring Ins cti By Date Co t ted Well Depth ft <br /> COMMENTS It [U 9 e --At x <br /> -'"_"_—Cak� – — <br /> PE SC Received Check#/ Arhount Date Permit/ Invoice# WellID# <br /> Codes Info B Remitted Service Request#// <br /> EHD 43-05 WELL/PUMP PERMIT <br /> 4/30/12 <br />