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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 />NUN-KEFUNDABLE <br />GALL (2U9) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS <br />566 JOSEPH RD <br />crrymP MANTECA, 95336 <br />CROSS STREET N. <br />MAIN ST. <br />APN Z16- 1!!�PARCEL SIZE LAND USE APPLICATION # <br />OWNER NAME <br />SAL RODRIQUEZ <br />PHONE 209.470.3332 <br />OWNER ADDRESS <br />566 JOSEPH RD <br />CIN/STATE/ZIP MANTECA, CA. 95336 <br />CONTRACTOR <br />N & S IRRIGATION, <br />INC PHONE 209.599.3456 <br />CONTRACTOR ADDRESS 215W- MAIN STREET <br />CITY/STATE/ZIP RIPON. CA. 95366 <br />SUBCONTRACTOR <br />PHONE <br />SUBCONTRACTOR ADDRESS <br />LICENSE C-57 C-61 D-09 <br />CITY/STATE/ZIP <br />NUMBER 662732 EXPIRATION DATE 01/31/19 <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township _ Range Section <br />NTENDED USE X Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System <br />If different from Owner: Water system Name contact Name or Phone Numeer <br />TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br />Monitoring Well(s) # of wells Soil Boring(s) # of borings Geotechnical # of borings <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -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 1 Other <br />Proposed Well Depth ft Excavation in diameter I 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 I Steel Plastic Stainless Steel I Other <br />Grout Seal Depth ft Neat Cement (94/b bag/5-10 gal water) I 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 ft Thick in Christy Box Stove Pipe <br />PUMP XSubmersible Turbine Other HP 1.5 Pump Set 80 It Standing Water Level 25 ft <br />I HEREBY CERTIFY TH T I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />J04wtY'6�UNTY O NANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CYIRRENT AND ACTT E WITH T}IE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />SIGNED <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-76997 G <br />TITLE 1 j " Av i [ `) "L`%�'V DATE 1 1 — It I IL <br />EP RTMENT USE <br />N Y <br />Date v v <br />Date 1 <br />Date <br />Date <br />Area Employee ID#jVA& <br />PECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth ft <br />N <br />N <br />v <br />- JeNi <br />V <br />- C�2018 <br />N JOAQU�N <br />LTy E qR �ly1Y <br />ENT <br />PESC Received Chec <br />Codes Info B Cash <br />Amount <br />Remitted <br />Permit/ <br />Date Service Request # Invoice# WeIIID# H <br />a i 3 <br />-� <br />z2 is �v bo3 <br />EHD 43-06 WELL /PUMP PERMIT <br />4130/12 <br />