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4 <br />WELL/PUMP PERMIT RECEIVED <br />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 ISSU <br />jyj <br />JOB ADDRESS .5.261 NILE RD / CITY/ZIP MANTECA, 95337 <br />CROSSSTREET nl FANnCO �If Rn APN �j (i(J�O /?- PARCEL SIZE LAND USE APPLICATION# l•.NV IIZI <br />OWNER NAME CHARLES CALDWELL PHONE 209.679.1409 D1 <br />OWNERADDRESS 5261 NILE RD CITY/STATEIZIP MANTECA. CA. 95337 <br />CONTRACTOR N & S IRRIGATION, INC PHONE 209.599.3456 <br />CONTRACTOR ADDRESS 215 W MAIN STREET CITYISTATE/ZIP RIPON, 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 Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System <br />If different from Owner: Water ys etn Name on a .—Olpnone um r <br />TYPE OF WORK New Well Replacement Well i Well Alteration/Modification i Other <br />Monitoring Well(s) # of wells Soil Boring(s) # of borings Geotechnical # of borings <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 />WELL CONSTRUCTION <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 irT&A!�e <br />Conductor Casing in diameter / Conductor Casing Depth ft EAn <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) 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 It Length ft Thick in Christy Box i Stove Pipe <br />PUMP XSubmersiblei Turbine i Other HP—j— Pump Set A0 It 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 />NTY <br />ES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED <br />NSE IS <br />IA <br />RS STATE <br />ICENSE BOARD <br />ND THAT I AM IN <br />LIANCE <br />COA ENT O M AM ?�A�HREIIVI6Nd RN OTICETREOlO11RED FORLINSPECTIONSA PLEASE CALL 1209/953 �s 7ETH ALL <br />RKERS C MPENS TI NLA <br />E <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />TITLE ' `R ' " A -C' � DATE <br />RTMENT USE yLY <br />--I Date <br />Date <br />Dale <br />Date <br />MENTA1,1IEALTt <br />ARI-N1LNT <br />c <br />�4-4fr <br />�VFD <br />Y 14 2018 <br />QUIN fpMFNTAt <br />ARTMENT <br />Area S L Employee ID#j�� <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth ft <br />PE SC Received ecAmount <br />Codes Info B <br />Permit/ <br />emitted Date Service Request # Invoice # Well ID# <br />��34 <br />5 l6 3£�Zln <br />EHD 43-06 <br />4/30/12 <br />WELL /PUMP PERMIT <br />