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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 />NC1N-RFFI INr1AR1 F PFRMIT CALL 12091 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS <br />2005 W LQUISE AVE CITYIZIP MANTECA 95338 <br />N1 <br />�DZZO <br />CROSS STREET <br />AIRPORT WAY APN PARCEL SIZ�I.^E-rTy_-LAND USE APPLICATION # <br />ROECKLE%rArflo L�1J $ ��YI M I.Je-I 19el '+ 702.563.9452 <br />OWNER NAME <br />MARIE PHONE <br />OWNER ADDRESS <br />2005 W. LOUISE AVE CITY/STATE/ZIP MANTECA, CA. 9533 <br />CONTRACTOR <br />N & S IRRIGATION, INC PHONE 209.599.3456 <br />CONTRACTOR ADDRESS 215 W MAIN STREET CITYISTATE/ZIP RIPON, CA. 95366 <br />SUBCONTRACTOR <br />PHONE <br />SUBCONTRACTOR <br />ADDRESS CITY/STATE/ZIP <br />LICENSE C-57 <br />1 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 <br />Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring 1 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 Well Alteration/Modification Other <br />Monitoring Well(s) # of wells Soil Boring(s) # of borings Geotechnical # of tonnes P <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />New Pump X Pump Replacement Pump Repair Raise Well Casing <br />W ELL CONSTRUCTION <br />Drilling Method <br />Mud Rotary Air Rotary Auger Cable Tool r Push Point Other <br />Proposed Well <br />Depth ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size in d.YnfY.r <br />Conductor Casing in diameter / Conductor Casing Depth ft $� <br />Well Casing <br />JO <br />Diameter_ in Thickness/Gauge/ASTM Schad 1 Steel 1 Plastic Stainless Steel 1 Other AQ <br />Grout Seal <br />Depth ft Neat Cement (94 /b bag/5-10 gal water) 1 Sand Cement sack A 7L <br />�E <br />Bentonite (20% solids) Other <br />Grout Placement Method Pumped Free Fall Other Retardant / Accelerator (name) <br />PEDESTAL <br />Installed By Driller Pump Contractor Other <br />Concrete Pedestal Dimensions: Width ft Length It Thick in Christy Box Stove Pipe <br />PUMP <br />XSubmersible- Turbine Other HP- Pump Set 63 It 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 />,10AQDIN�COUNTY ORDI ANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIV WITH T E ALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS 0OMPENS ON LAW . s 4 <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />TITLE 1 17 1 IU"` I� � DATE & r 1 / <br />N <br />m <br />D <br />A <br />N <br />ENT <br />vEID <br />92018 <br />ullilry <br />EN-rAL <br />I,Rr NT <br />TMENT U E Y <br />Date Area I�3 d EmployeelD#� <br />Date SPECIAL Well Permit <br />Date p _ WAIVER Received <br />Date ( Constructed Well Depth ft <br />PE <br />Codes <br />SC Received eck#/ Amount Permit/ <br />Info B s emitted Date Service Re uest # Invoice # Well ID# <br />N1 <br />TIP a �-� -A� VV QOo � z <br />EHD 43-06 <br />4/30112 <br />WELL /PUMP PERMIT <br />