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1v WtA 5 Lir \ - I'll, -0 O� <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209) 468-3420 <br />n1UP4-K6FUNUABLE PERMIT GALL (ZU9) 953-7697 FOR INSPECTIONS <br />EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS <br />2901 BRONZAN RD <br />CIT,,1ZjP <br />MANTECA 95336 <br />CROSS STREET <br />MCKINLEY AVE APN.Z+l—Al <br />OPARCEL SIZE j <br />_LAND USE APPLICATION# <br />OWNER NAME <br />GARY CHRISTEN <br />PHONE 209.823.3255 <br />OWNERADDRESS <br />2901 BRONZAN RD <br />CITY/STATEMP <br />MANTECA, CA 95336 <br />CONTRACTOR <br />N & S IRRIGATION, INC <br />PHONE 209.599.3456 <br />CONTRACTOR ADDRESS 215W. MAIN STREET <br />CITY/STATE/ZIP <br />RIPON CA. 95366 <br />SUBCONTRACTOR <br />PHONE <br />SUBCONTRACTOR ADDRESS <br />LICENSE 7 C-57 -1 C-61 ❑ D-09 <br />CITY/STATE/ZIP <br />NUMBER 662732 EXPIRATION <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br />INTENDED USE Domestic/Private Irrigation/Agricultural I Industrial F Water Quality Monitoring L Soil Sampling/Characterization <br />Public Water System <br />If different from Owrer Water system Name Contact Name or Pnone Number <br />TYPE OF WORK - New Well 7 Replacement Well Well Alteration/Modification = Other <br />L Monitoring Well(s) # of wells` Soil Boring(s) ° of borings L Geotechnical # of borings <br />Out -0f -Service Well i Out -Of -Service Well Renewal L Cross -Connection Repair <br />11 <br />Drilling Method :i Mud Rotary Air Rotary I Auger Cable Tool I Push Point Other <br />Proposed Well Depth ft Excavation in diameter I Open Bottom P Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth It <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched I Steel L Plastic L Stainless Steel L', Other <br />Grout Seal Depth ft i Neat Cement (94 Ib bag/5-10 gal water) Sand Cement sack mix17 gal water <br />Bentonite (20% solids) 1 Other <br />Grout Placement Method -1 Pumped ',1 Free Fall F Other r° Retardant / Accelerator (name) <br />PEDESTAL Installed By _i Driller I Pump Contractor L Other <br />Concrete Pedestal ;Dimensions: Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br />PUMP XSubmersible -1 Turbine 11 Other HP 3/4 Pump Set ---5.Q— ft Standing Water Levelgip— 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. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CUR5_Enj AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />W ERS MPEN TION LAWS. <br />I I U HOU�A W E REQUIRED FOR <br />INSPECTIONS - PLEASE CALL (209) 953-7697 T <br />SIGNED TITLE I P�YIr U/II�P� DATE <br />EP RTMENT USE ONLY <br />Application Accepted B Date <br />Grout Inspection By Date <br />Pump Inspection By Date <br />Soil Boring Inspection By , I Date <br />COMMENTS Or r 0G <br />m <br />N <br />D <br />CEIVED <br />JAN 0 6 2017 <br />AreaployeelD#VWr S <br />SPECIAL Well Permit <br />Ll WAIVER Received <br />Constructed Well Depth ft <br />PE SC <br />Codes Info <br />Received jdhsqfflP AmountDatePermit! Invoice# WeIIID# <br />B 9h Remitted Service Re uest # <br />.21��• o , (-00`7(6 �6�3�wv <br />EH D 43-00 WELL /PUMP PERMIT <br />4/30112 <br />HEALTH <br />