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M <br />m <br />nt <br />T. <br />s� <br />0 M <br />U <br />H <br />Z <br />LJJ <br />Z <br />IL <br />PAY <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN-KEFUNDA13LE YERM I l- LU7 y041-/09/ t -UK INW-LL, IIUNJ onnrcrw I T CNK rKUIVI LJAI C IJJUCU <br />JOB ADDRESS 12911 GRAVES RD <br />CITYIZIP Mf/(At�NTECA 95336 <br />CROSS STREET JACK TONE R� D APN <br />I� <br />v D PARCEL SIZE"AND USE APPLICATION # <br />OWNER NAME CLIF�VANDERVEEN fpp}��y�I+� <br />PHONE 599.2746 <br />U <br />OWNER ADDRESS 12911 GRAVES RD /7it779(,� <br />CITY/STATE/ZIP MANTECA, CA. 95336 <br />� <br />CONTRACTOR N & S IRRIGATION. INC <br />PHONE 209.599.3456 <br />CONTRACTOR ADDRESS 215 W MAIN STREET <br />CITY/STATE/ZIP RIPON, CA 95366 <br />SUBCONTRACTOR <br />PHONE <br />SUBCONTRACTOR ADDRESS <br />CITY/STATE/ZIP <br />L <br />LICENSE C-57 C-61 D-09 XOther <br />C10 NUMBER 662732 EXPIRATION DATE 01/31/19 <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township _ Range Section <br />NTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System <br />If different from Owner Water System Name Contact ame or one um or <br />TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br />Monitoring Well(s) # of wells Soil Boring(s) 0 of borings Geotechnical a of borings <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />New <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 bag/5-10 gal wafer) 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 DimensionsWidth ft Length ft Thick in Christy Box Stove Pipe <br />PUMP XSubmersib e Turbine Other HPPump Set�Q� ft Standing Water Level ft <br />I HE CERTIFY THAT I HAVE PREPARED THIS APPL�OkTION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />J QUINUNTY 0 NANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />RRENT A D ACTAVE 444TH THI} CA61FORNIA CONT ACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />INIMUM 24 O t A NC NOMI REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7 7 <br />SIGNED TITLE I Y -" k270�' DATE <br />SAN JOA(IUIPJ <br />HEALTH <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />ARTMENT�UI <br />Date <br />_ Date j <br />Date . <br />Date <br />`l1 <br />ry <br />Area-+ Employee ID#/./ <br />CI SPECIAL Well Permit <br />7 WAIVER Received <br />Constructed Well Depth ft <br />PE SC Received Checli;V Amount Date Permit/ Invoice # Well ID# <br />Codes Info B Remitted Service Re uest# <br />La dt%C J <br />EHD 43-06 <br />4/30/12 <br />WELL /PUMP PERMIT <br />