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• 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 1276 S AIRPORT WAY CITY/ZIP MANTECA 95337 <br /> 0 <br /> CROSSSTREET W. LOUISE AVE. APN -- ARCEL SIZE LAND USE APPLICATION# m <br /> OWNER NAME BETTY OTT PHONE 209.595.8000 y <br /> OWNER ADDRESS 5612 USTICK RD CITY/STATE/ZIP MODESTO, CA. 95358 <br /> CONTRACTOR N &S IRRIGATION, INC PHONE 209.599.3456 <br /> CONTRACTORADDRESS 21.5 W- MAIN STREET __ _ CITY/STATE/z,P RIPON CA. 95366 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C-57 C-61 D-09 XOther C10 NUMBER 662732 EXPIRATIONDATE 01/31/19 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section <br /> INTENDED USE Domestic/Private Irrigation/Agricultural i Industrial Water Quality Monitoring ,Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water System Name Comad Name or one Number <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br /> MonitoringWell(s) #of Wells SoilBoring(s) #ofbonngs Geotechnical #ofbonngs <br /> Out-Of-Service Well Out-Of-Service Well Renewal ICross-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 Neat Cement(94 lb bagl5-10 gal water) Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method r Pumped Free Fall i i Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width It Length ft Thick in - Christy Box Stove Pipe <br /> PUMP XSubmersible� Turbine Other HP___J_ Pump Set Fin ft Standing Water Level--20—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 /> CU ND AC VE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WOR RS MPE TIO�LAWM <br /> I MU 4 HR NC CE REQUIRED FOR G I�NSPECTTIIONNS-PLEASE CALL(209)953-76 7 <br /> SIGNED TITLE N&I�(�3C rL� DATE171 vw-- <br /> L� <br /> N <br /> VV E <br /> S1 I I I I I I I <br /> CEIVELJ <br /> AR z 3 Zona <br /> TP <br /> ' - <br /> AMENTAL HEALTH <br /> r- MIT/SERV CES <br /> a> c) p <br /> .� . AYh1EE <br /> a ' RECEIVD <br /> a . AR? <br /> ?417 <br /> QAQt// <br /> (, H M7RONMECOU <br /> V - <br /> �DEa,�p�al <br /> C C� E P R T M E N T S E N L Y ��� ����� �MEh r <br /> 34 <br /> CD 1,,Application Accepted By Date Area mployee ID# <br /> E � Grout Inspection By Date SPECIAL Well Permit <br /> j IE :>� Pump Inspection By Date – WAIVER Received <br /> in Boring Inspection By Date J Constructed Well Depth ft <br /> 0). COMMENTS M1 ({�C QY� JI�►iJ ' ( ,zn l _, i L�(% I�� <br /> PE SC Received Chec Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B ash Remitted Service Request# <br /> 14?X ND F.o o c1 <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4/30/12 <br />