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RECEIVED <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-31 1 1 z0�8 <br />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSU <br />JAY <br />JOB ADDRESS 1230 CORWIN DR- �J CITY/ZIP MANTF A 95337 is NVI IW? <br />CROSS STREET UNION RD APN '�J <br />?jZ' f0 PARCEL SIZELAND USE APPLICATION # DI' <br />OWNER NAME LOURRAINE FREITAS PHONE 823.3356 <br />OWNER ADDRESS 1230 CORWIND DR CITY/STATE/ZIP_ MANTECA CA 95337 <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 />ADDRESS <br />LICENSE C-57 C-61 D-09 <br />CITYISTATE/ZIP <br />XOther C 1 0 NUMBER 662732 EXPIRATION DATE 01/31/19 <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br />INTENDED 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 <br />Monitoring Well(s) # of wells <br />Out -Of -Service Well <br />New Pumo X Pump Replacement <br />Well Alteration/Modification Other <br />SoilBoring(s) #ofbonngs Geotechnical <br />Out -Of -Service Well Renewal Cross -Connection Repair <br /># of bonngscc^^.... <br />-%N <br />WELL CONSTRUCTION ' •Cft��-` <br />Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other ,,77 <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 water) Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) 1 Other <br />Grout Placement Method Pumped 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 � Pump Set 6f ft Standing Water Level 3, ft <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 />C ND ACTIV WITH THE CA IFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />KERS MPEN ON LA S. <br />1N M H UR D A C�EQUIRED FO/R� I/N�S�P/EQCT/IO�NSf-JPLEASE CALL (209) 953-7697 <br />SIGNED DATE <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />EP RTMENT U L tEN Y <br />r Date T i <br />Date <br />Date <br />Date <br />ENTAL IIEALT1 <br />I2"1'nIIN"T <br />y�FNT <br />Areamployee ID#14~ <br />SPECIAL Well <br />Permit <br />- WAIVER Received <br />Constructed Well Depth ft <br />PE SC Received pfiedo Amount Date <br />Codes Info B Remitted <br />Permit/Invoice # Well ID# <br />Service Re uest# <br />�j <br />EHD 43-06 WELL /PUMP PERMIT <br />4/30/12 <br />