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Pj "q,* E1 REGEN I OCi 3 i Wks JOA�Uf HEA= P/ WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NUN-KEFUNDABLE YE MI I UALL 1U7 V34 -10W/ FUK I1%l31'tt, I IUNJ CArlr[CJ I T LAK I'KVM UA It IDDULU JOB ADDRESS 619 JOSEPH RD 43�J �S CITYIZIP MANTECA, 95336 CROSS STREET MAIN ST APN ( ♦!•� V(/(/ '1 PARCEL SIZE O / �J/ t� LAND USE APPLICATION # OWNER NAME ANDREI ROCHA Abe . Julia-na RD r hC( PHONE 623-8302 OWNERADDRESS 619 JOSEPH RD CITY/STATE/ZIP MANTECA, CA 95336 CONTRACTOR N & S IRRIGATION, INC PHONE 209.599.3456 CONTRACTOR ADDRESS 215 W. MAIN STREET CITY/STATE/ZIP RIPON, CA. 95366 SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE C-57 C-61 D-09 XOther �+ C 1 0 NUMBER 662732 EXPIRATION DATE 01 /31 /19 GEOGRAPHICAL INFORMATION: Coordinates X Y Township _ Range Section NTENDED USE Domestic/Pdvate Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization Public Water System If different from Owner: Water System Name contact ame or one umbe, TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other Monitoring 1,Nell(s) # of velis Soil# of borings Boring(s) .Geotechnical # of borings Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair New Pumo X Pump Replacement Pumo Repair Raise Well Casing WELL CONSTRUCTION Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other Proposed Well Depth ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter _ in Thickness/Gauge/ASTM Schad Steel Plastic Stainless Steel Other Grout Seal Depth ft Neat Cement (94/b bag/5-10 gal water) Sand Cement sack mixl7 gal water Bentonite (20% solids) Other Grout Placement Method Pumped Free Fall Other Retardant / Accelerator (name) PEDESTAL Installed By Driller Pump Contractor Other Concrete Pedestal Dimensions: Width ft Length ft Thick in Christy Box Stove Pipe PUMP XSubmersible. Turbine Other HP ___I__ Pump Set__A3__ ft Standing Water Level ___23_ ft I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUN'G19ls1NTY 0ADINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS C)ARENT ANh ACTIVE WITH TAE C&IFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL MINIMUMI24 HOIUR Application Accepted By Grout Inspection By Pump Inspection By Soil Boring Inspection By COMMENTS REQUIRED FOR INSPECTIONS -- PLEASE CALL (209) 953-7697 TITLE DATE — I DEPARTMENT USE ONLY Date Date Date Date ■■■EEME■EEMEME■ ■■■EEMEME■■■EE■ NE■EEME■EE■EE■E ■E■EEME■■EME■■E ■■■EEME■■EEMEE■ ■■EE■■EME■■■E■■ ■■■■NEEM■M■■■■■ NEEM■■■■■■■\(■■■ ■E■■■■■■■EE■8EE ■E■■■■■■MEM■►NM■ ■E■E■■■■E■■ NEM■■EE■■■■ is ■■■■■M■■■■■ ■F'M■ ■■■■■■■■■■■ ■"INE ■■■■■■■■■■■■NNE w 3 C3 M q 0 PE Codes SC Received Info By (—CheckV Amount Date Remitted Permit/ Invoice # Well ID# Service Re uest # 43�J �S X595 4D 575 EHD 43 -De WELL /PUMP PERMIT 4/30/12