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P✓ <br />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) 9&3-7ti97 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />ADDRESS 22501 OLEANDER AVE cITY/ZIP MANTECA 95337 <br />SSSTREET E. NILE AVE APN '� O PARCELSIZE LAND USE APPLICATION# <br />ER NAME FRANK CASTRO tvN PHONE 481.3886 <br />SER ADDRESS 22501 OLEANDER AVE Cr, -?,CV NIJ& CITY/STATE/ZIP MANTECA, CA 95337 <br />TRACTOR N & S IRRIGATION, INC PHONE 209.599.3456 <br />TRACTORADDRESS 215W- MAIN STREET CITY/STATE/ZIP RIPON, CA. 95366 <br />-ONTRACTOR PHONE <br />ADDRESS <br />CITY/STATE/ZIP <br />LICENSE C-57 C-61 D-09 XOther C 1 0 NUMBER 662732 EXPIRATION DATE 01/31/19 <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township _ Range Section <br />INTENDED USE DOmestic/Pnvate Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System <br />If different from Owner Water System Nam ContaCt Name or Phone um r <br />TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br />Monitoring Wells) # of wells Soil Boring(s) # of borings Geotechnical # of borings <br />Gut-O"Satiice b"Jeil Out-Of-Service'llell Renewal Cross -Connection Repair <br />New Pump A 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 Schad Steel i Plastic Stainless Steel Other <br />Grout Seal Depth ft Neat Cement (94/b bag/5-10 gal water) i Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method Pumped Free Fall Other Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor Other <br />Concrete Pedestal Dimensions: Width ft Length It Thick in Christy Box Stove Pipe <br />PUMP XSubmersible. Turbine Other HP__IL_ .5 Pump Set_BD_ It Standing Water Level �2_ ft <br />1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />AQUI COUNTY DINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT ND A IVE WITH THE LIFORNIA CONJRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />.WORKERS OMP SATION <br />IM 24 OU A VAN N ICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 95,1-7697 <br />TTITLE _r1� DATE <br />REC <br />DEC <br />PAYMENT <br />RECENE� <br />IDIE�a Application Accepted By <br />�J CgU►7T / Grout Inspection By <br />SAN JOP.QU <br />ENJROEPA TVEH7 Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />0 <br />TMENT US)E OLY <br />Date <br />Date <br />Dale <br />Date <br />0 <br />in <br />Area Employee ID# JAC71POIJt I/ <br />PECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth It <br />PE SC Received Chat: Amount Perm b <br />Codes Info B ash Remitted Date Service Re uest # Invoice # Well ID# <br />M D50 411A -260vf jA) r06 37(e,&-2 <br />EHD 43-06 WELL /PUMP PERMIT <br />4130/12 <br />