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14 <br />-Tr Aw� � (atn I <br />WELL/ -M-7UMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />PIVrv-RCFUNUAtfLt rLKMI I t;ALL (LUV) UOJ-/697 FOR INSPECTIONS <br />EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS <br />13790 S. HWY 99 <br />CITY/ZIP <br />MANTECA 95336 <br />CROSS STREET <br />NORTHLAND APN <br />t ` _1 <br />PARCEL SIZE LAND USE APPLICATION # <br />OWNER NAME <br />TROY BARGER <br />PHONE 209.823.3255 <br />OWNER ADDRESS <br />13790 S. HWY 99 <br />CITYISTATEIZIP <br />MANTECA, CA 95336 <br />CONTRACTOR <br />N & S IRRIGATION, INC <br />PHONE 209.599.3456 <br />CONTRACTOR ADDRESS 215 W. MAIN STREET <br />CITYrSTATE/ZIP_RIPON, <br />CA. 95366 <br />SUBCONTRACTOR <br />PHONE <br />ADDRESS <br />-I C-57 n C-61 -1 D-09 XOther <br />CITY/STATE21P <br />NUMBER 662732 EXPIRATION <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section <br />INTENDED USE Domestic/Private "1 Irrigation/Agricu@ural L Industrial C' Water Quality Monitoring G Soil Sampling/Characterization <br />Public Water System <br />If different from Owner: water System Name ContaCt Name or Phone 1,16.er <br />TYPE OF WORK 1 New Well ❑ Replacement Well F Well Alteration/Modification C Other <br />J Monitoring Well(s) # of wells Soil Boring(s) # of borings L Geotechnical # of borings <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />New Pump xi Pump Replacement Pump Repair Raise Well Casino <br />Drilling Method i Mud Rotary ❑ Air Rotary Auger Cable Tool Push Point Other <br />Proposed Well Depth ft Excavation _ in diameter 0 Open Bottom L Gravel Pack/Gravel Size in diameter <br />C Conductor Casing in diameter / Conductor Casing Depth It <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched h Steel L Plastic L Stainless Steel C Other <br />Grout Seal Depth ft 1 Neat Cement (94 Ib bag/5-10 gal water) L Sand Cement Sack mix/7 gal water <br />J Bentonite (20% solids) "I Other <br />Grout Placement Method ❑ Pumped Free Fall F Other Retardant /Accelerator (name) <br />PEDESTAL Installed By -1 Driller ❑ Pump Contractor L Other <br />Concrete Pedestal i, Dimensions: Width ft Length ft Thick in L Christy Box ❑ Stove Pipe <br />PUMP XSubmersible 1 Turbine 7 Other HP 1 112 Pump Set 6jQ ft Standing Water Level 42 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 />CURREtJ7�AND APIVE WITH,THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />4 H)O D NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-76977 Imo,am' <br />SIGNED l TITLE- ,PL DATE - 50-1 J <br />X <br />LA <br />D <br />PA <br />yAISIVT <br />REcENED <br />Atj 10 2017 <br />Ziwh <br />06 2017 <br />HEAL -FH <br />P RTMENT SE NLY <br />Application Accepted B Date ( Area Employee ID#IJ�� <br />Grout Inspection By Date ^7 J SPECIAL Well Permit <br />Pump Inspection By Date // W 7 11 WAIVER Received <br />Soil Boring In tion By Date T Constructed Well Depth - It <br />PE SC Received #/ Amount Date Permit/ Invoice # Well IDN <br />Codes Info B Remitted Service Re uest # <br />D5� X4.5 n O.0 WP0031b31 <br />EHD 43-06 WELL /PUMP PERMIT <br />4/30/12 <br />