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v � , <br />WELL/PUMP PERMIT <br />r SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE -STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 581 WAUSTIN RD CITY/ZIP MANTECA 95336 <br />CROSS STREET HM 120 AP O PARCEL SIZE " LAND USE APPLICATION # <br />OWNER NAME ARTMATH IAS f7prbara %) T PHONE 239.2212 <br />OWNERADDRESS 581 . AUSTIN RD. CITY/$TATE/ZIP MANTECA, CA. 95336 <br />CONTRACTOR N & S IRRIGATION, INC PHONE 209.599.3456 <br />CONTRACTOR ADDRESS 215 W MAIN STREET CITY/STATE/ZIPIF2 PON CA 95366 <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br />LICENSE C-57 C-61 D-09 XOther C10 NUMBER 662732 EXPIRATION DATE 01/31/19 <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section <br />INTENDED USE X Domestic/Private i Irrigation/Agricultural i Industrial i Water Quality Monitoring ' i Soil Sampling/Characterization <br />Public Water System <br />If different from Owner: Water system Name Contact Name or Phone Number <br />TYPE OF WORK <br />New Well Replacement Well n Well Alteration/Modification Other <br />Monitoring Well(s) # of wells . i Soil Borings) n of boring. Geotechnical <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />Drilling Method Mud Rotary Air Rotary Auger i Cable Tool -I Push Point <br /># of borings <br />Proposed Well Depth ft Excavation in diameter i Open Bottom i 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 I Plastic C Stainless Steel 11 Other <br />Grout Seal Depth ft Neat Cement (94 Ib bag/5-10 gal water) i Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method Pumped :1 Free Fall i i Other Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor Other <br />Concrete Pedestal Dimensions: Width ft Length ft Thick in Christy Box I Stove Pipe <br />PUMP XSubmersible Turbine ' Other HP 1.5 Pump seiL 80 ft Standing Water Level ft <br />I HEREBY CERTIFY TH T I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAO NTY O INANCES, STATE LAWS, AND RUL AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CU NT AN ACTT WITH T E LIFORNIA CON TORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WO ERS COMPEN O LAW / <br />M 4 R D A CE REQUIRED FOUR INSPEC IONS :PLEASE CALL (209) 953-76 7 <br />SIGNED ( TITLE Vi DATE <br />_y <br />a <br />0 <br />mm <br />N <br />Application Accepted By 11,W1a Date 1 1 Area d:Employee ID#//~ <br />Grout Inspection By jj Date L7 SPECIAL Well Permit <br />Pump Inspection By 1 Date r Z ❑ WAIVER Received <br />EcF CEO <br />Soil Boring Inspection By Date Constructed Well Depth ft ,Jq <br />COMMENTS ,�+�p <br />2(r /05 <br />JOA QU <br />PE v,RON/N COiN ry <br />Codes <br />SC <br />Info <br />Received <br />Check#/ <br />Amount <br />Remitted <br />Date <br />Pef"'Iu Invoice # Well ID# <br />ry <br />Oh <br />Ias 2 <br />e6uest# <br />Ty pANR At <br />Soil Boring Inspection By Date Constructed Well Depth ft ,Jq <br />COMMENTS ,�+�p <br />2(r /05 <br />JOA QU <br />PE v,RON/N COiN ry <br />Codes <br />SC <br />Info <br />Received <br />Check#/ <br />Amount <br />Remitted <br />Date <br />Pef"'Iu Invoice # Well ID# <br />ry <br />Oh <br />Ias 2 <br />-t5-D <br />EHD 43-06 <br />4/30112 <br />WELL /PUMP PERMIT <br />