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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 />IVUIY-RtrUNUAOLt rtKMI I VALL tLVV) 53J-1001 tUK INSYtk:11UNV <br />CArIMr-Q 1 T tAK rKUM IJA I t I,SUtU <br />JOB ADDRESS <br />2807 S. AIRPORT WAY <br />CITY/ZIP <br />STOCKTON, 95206 <br />CROSS STREET <br />E 10TH STREET APN <br />O <br />PARCELSIZW"LAND USE APPLICATION # <br />OWNER NAME <br />CERRI RENTAL <br />PHONE 209.471.6764 <br />OWNERADDRESS <br />2807 S. AIRPORT WAY <br />1 <br />7i CITY/STATE2IP <br />STOCKTON, CA 95206 <br />CONTRACTOR <br />N & S IRRIGATION, INC <br />PHONE 209.599.3456 <br />CONTRACTOR ADDRESS 215W. MAIN STREET <br />CITY/STATE2IP <br />RIPON, CA, 95366 <br />SUBCONTRACTOR <br />PHONE <br />SUBCONTRACTOR ADDRESS <br />LICENSE C-57 ❑ C-61 -j D-09 <br />CITY/STATE/ZIP <br />XOther C10 NUMBER 662732 EXPIRATION DATE 01/31/19 <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br />INTENDED USE Domestic/Private , Irrigation/Agricultural D Industrial -I Water Quality Monitoring i Soil Sampling/Characterization <br />Public Water System <br />If different from Owner: water bY5t8M Nam on a arae or one um r <br />/ <br />TYPE OF WORK New Well - Replacement Well D Well Alteration/Modification i Other <br />Monitoring Well(s) # of wells i i Soil Boring(s) # of borings I..I Geotechnical # of borings <br />Out -Of -Service Well D Out -Of -Service Well Renewal ,, Cross -Connection Repair <br />New Pump X Pump Replacement Pump Repair i Raise Well Casino <br />Drilling Method Mud Rotary - Air Rotary Auger Cable Tool n Push Point i Other "W V <br />Proposed Well Depth it Excavation in diameter D Open Bottom 7 Gravel Pack/Gravel Size in It.; <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched :1 Steel D Plastic D Stainless Steel El Other <br />Grout Seal Depth ft Neat Cement (94 Ib bagl5-10 gal water) a Sand Cement sack mix17 gal water <br />- Bentonite (20% solids) Other <br />Grout Placement Method D Pumped Free Fall ❑ Other I Retardant / Accelerator (name) <br />PEDESTAL Installed By � Driller j Pump Contractor I Other <br />- Concrete Pedestal Dimensions: Width ft Length It Thick in Christy Box i Stove Pipe <br />PUMP XSubmersible Turbine ii Other HP__L5-- .5 Pump Set 120 ft Standing Water Level �� ft <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />J06PULUX,OUNTY ORDI"NCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />QdRRENT AtjD ACTIVEMTH THE ICAI FORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS PENSA ON LAWS./ /' % <br />n!"A!jNC <br />/1,N EQUIRED FORINSPECTIONS- PLEASE CALL (209), -7697 <br />SIGNED -TITLE DATE <br />PA TMENT SE N}.�Y <br />1 Application Accepted By Date (�i/ <br />Grout Inspection By Date If A <br />Pump Inspection By Date <br />Soil Boring Inspection By Date <br />COMMENTS <br />Area Employee ID#% <br />SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth ft <br />rA <br />D <br />O <br />M <br />w <br />PE SC Received <br />Codes Info By <br />Che Amount Date Perm1U Invoice# Well ID# <br />s Remitted Service Re uest# <br />;? _7 <br />EHD 43-06 WELL /PUMP PERMIT <br />4/30/12 <br />?2 "018 <br />qN C <br />MENr4.N?Y <br />