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REvN <br />pgG 11 <br />u1 <br />SXS <br />eoa of <br />Pf <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN-KEFUNUABLI- YtKMIl UALL LV7 V0S-/07/ FUK INJYtL; IIUNS <br />CAr IKCii I TtAK t-KUM UA It Ibb UtU <br />JOB ADDRESS <br />5220 ALMONDWOOD F+& D(' <br />f CITY/ZIP <br />MANTECA, 95337 <br />CROSSSTREET <br />OLEANDER AVE APN —OAx <br />O PARCEL SIZE LAND USE APPLICATION# <br />NAME <br />It,OWNER <br />LUIS BRIZUELAVt _�i.1CLlLlT[� <br />Diameter _ in Thickness/Gauge/ASTM Sched <br />PHONE 409.9173 <br />OWNER ADDRESS <br />5220 ALMONDWOOD RD <br />CITY/STATE/ZIP <br />MANTECA, CA. 95337 <br />CONTRACTOR <br />N & S IRRIGATION, INC <br />PHONE 209.599.3456 <br />CONTRACTOR ADDRESS 215 W. MAIN STREET <br />CITY/STATE/ZIP <br />RIPON CA, 95366 <br />SUBCONTRACTOR <br />Installed By Driller Pump Contractor <br />Other <br />PHONE <br />ADDRESS <br />C-57 C-61 D-09 <br />CITY/STATE/ZIP <br />XOther C 1 0 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 Name or Phone NUMber <br />TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br />MonitoringWell(s) #of wells SoilBodng(s) #ofbonngs Geotechnical #ofbonngs <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />New Pumo X Pump Replacement Pump Repair Raise Well Casino <br />Drilling Method <br />Mud Rotary Air Rotary Auger <br />Cable Tool Push Point Other <br />Proposed Well <br />Depth ft Excavation <br />in diameter <br />Open Bottom Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / <br />Conductor Casing Depth ft <br />Well Casing <br />Diameter _ in Thickness/Gauge/ASTM Sched <br />Steel Plastic Stainless Steel 1 Other <br />Grout Seal <br />Depth ft Neat Cement (94 <br />lb bag/5-10 gal water) <br />Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method Pumped Free Fall Other <br />Retardant / Accelerator (name) <br />PEDESTAL <br />Installed By Driller Pump Contractor <br />Other <br />Concrete Pedestal Dimensions: Width <br />ft Length <br />It Thick in Christy Box Stove Pipe <br />PUMP <br />XSubmersible Turbine Other <br />HP 1 <br />Pump Set 60 ft Standing Water Level 11.5 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 />CURRENT—AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />MI I MU 4 HDV FE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED' TITLEN DATE <br />Application Accepted -ay <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />EPR "TM U E 0 N L Y <br />it Ll <br />Date <br />Date <br />Date <br />Area Employee ID#� <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth ft <br />PE SC Received Chec <br />Codes Info B <br />Amount Date Permit/ Invoice # Well ID# <br />Remitted Service Request # <br />- <br />0- i P"b <br />EHD 43-06 WELL /PUMP PERMIT <br />4/30/12 <br />0 <br />