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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1 B68 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 /> to <br /> JOB ADDRESS 1276 S AIRPORT WAY CITYIZIP MANTECA 95337 <br /> a <br /> Y/ 0 <br /> CROSSSTREET W. LOUISE AVE. APN ✓ ARCEL SIZE LAND USE APPLICATION# <br /> OWNER NAME BETTY OTT _ PHONE 209,595.8000 <br /> OWNER ADDRESS 5612 USTICK RD CITWSTATEIZIP MODESTO, CA.95358 <br /> CONTRACTOR N$S IRRIGATION INC PHONE 209.599.3456 <br /> CONTRACTOR ADDRESS 215W- MAIN STREET CRYISTATEIZIP RIPON- CA. 95366 <br /> SUBCONTRACTOR _ PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATEJZIP <br /> LICENSE C-57 C-61 I D-09 XOth., C10 NUMBER 662732 EXPIRATION DATE 01/31/19 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section <br /> INTENDED USE Domestic/Privale , IrrigalionJAgricullural -I Industrial -I Water Quality Monitoring i-Soil SamplinglCharacterizatian <br /> Public Water System <br /> Ifdiffamnt from Owner: a er ys em ame on a ame or one umber <br /> TYPE OF WORK New Well _ Replacement Well : Well APerationtModification a Other <br /> Monitoring Wells) #of wells Soil Borings) #of borings Geotechnical #of bonngs <br /> Out-Of-Service Well Out-Of-Service Well Renewal i Cross-Connection Repair <br /> New Pump X Pume Replacement Pump Repair Raise Well Casin <br /> W ELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point r Other <br /> Proposed Well Depth ft Excavation in diameter i Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter I Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad Steel -Plastic Stainless Steel -Other <br /> Grout Seat Depth ft Neat Cement(94 16 bag/5-10 gat water) L Sand Cement sack mix17 gal water <br /> - Bentonite(20%solids) Other <br /> Grout Placement Method LI Pumped -Free Fall H Other Retardant I Accelerator(name) <br /> PEDESTAL Installed By i Driller Pump Contractor Other <br /> - Concrete Pedestal-Dimensions:Width ft Length ft Thick in - Christy Bax i Stave Pipe <br /> PUMP - Submersibles." Turbine Other HP---J— Pump Seth]_ft Standing Water Level <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 /> CU ND AC VE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WO RS MPE TIO LAW <br /> I MU 4H UR NC CE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-76 7 <br /> SIGNED TITLE DATE <br /> N <br /> E <br /> S rAVE <br /> I NJ <br /> Li I <br /> AR 23 2017 <br /> NMENTAL HEALT14 <br /> --- #4 ITISERMES <br /> r�ED <br /> AR 2LV 2017 <br /> JGACxU �O <br /> i'x DF6.IM <br /> 'N ry <br /> EP' RTMENT SE NLY � "r <br /> Application Accepted By Date Area Impfoyee ID#Jay w <br /> Grout Inspection By Date SPECIAL WQII Permit IY <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Chet Amount Date Permit, Invoice# Well ID# <br /> Codes Info B ash Remitted Service Re uest# <br /> WELL 1PUMP PERMIT <br /> EHD 43-06 <br /> 4fd0112 <br />