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RECEIVED <br />Amount Permit/ <br />Remitted Date Service Request # Invoice # Well ID# <br />WELL/PUMP PERMIT <br />1 1 2018 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-34MAY <br />NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />ENVIR01 <br />IVIENTAL Ill,.: t"I'l <br />JOB ADDRESS CITY)/�ZIP��./may/MANTECA 95336 -D I;la�lll';elENl <br />%�t�,y/t,,� <br />E SOUTHLAND RD APIN �D r ' PARCELSIZA— / LAND USE APPLICATION# <br />m <br />CROSSSTREET <br />OWNER NAME RII 1 WHITESIDE PHONE 209 663 7645 <br />N <br />OWNER ADDRESS 15697 S AUSTIN RD CITY/STATE/ZIP MANTECA CA 95336 <br />CONTRACTOR N & S IRRIGATION INC PHONE 209.599.3456 <br />CONTRACTOR ADDRESS 215 W MAIN STREET CITY/STATE/ZIP RIPON, CA. 95366 <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br />LICENSE C-57 C-61 D-09 XOther C 1 0 NUMBER 662732 EXPIRATION DATE 01/31/19 <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township _ Range Section <br />INTENDED USE Domestic/Pnvate Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System <br />If different from OwnerWater System Name on a ame or one um er <br />. <br />TYPE OF WORK New Well Replacement Well I Well Alteraton/Modification Other <br />lyMonitoring <br />Well(s) # of wells a Soil Boring(s) # of borings Geotechnical R of borings <br />/���F�� <br />IM4 <br />Out -Of -Service Well Ll Out -Of -Service Well Renewal Cross -Connection Repair <br />New Pump X Pump Replacement n Pump Repair Raise Well CasingC <br />�AO <br />WELL CONSTRUCTION <br />1 <br />7 �O,D <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 <br />Conductor Casing n diameter / Conductor Casing Depth ft y DFAA <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched i Steel i Plastic Stainless Steel Other <br />RN041, <br />�, " <br />4Fj <br />Grout Seal Depth ft i i Neat Cement (94 Ib bag/5-10 gal water) i Sand Cement sack mix77 gal water <br />Bentonite (20% solids) h Other <br />Grout Placement Method Pumped i i 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__BD_ ft Standing Water Level <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />D'COUNTY FINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />URR NT AND AC VE WITH T}IE C LIFORNIA CON ACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />RKRS COMPE pyTION LA S. <br />U 4R ANE ICE REQUIRED FO�/RIINLS,P(EC�TIONS/- PLEASE CALL (209) 95697 <br />DATE <br />SIGNE <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />E P R T S 0 LY <br />Date <br />Dale 4 Area--*�— Employee ID#,o4yjtAjW <br />Date SPECIAL Well Permit <br />Date 2 _ WAIVER R@C@IVed <br />Date Constructed Well Depth ft <br />PE SC Received Che <br />Codes Info B ash <br />Amount Permit/ <br />Remitted Date Service Request # Invoice # Well ID# <br />EHD 43-06 WELL /PUMP PERMIT <br />4/30112 <br />