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• <br />s <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT <br />I.ALL (LU!51 WO.5-10JI I -UK INSYtL: IIUNS CArIRCJ I TCAK I-KUM WAIt ISSUCU <br />JOB ADDRESS 629 W YOSEMITE <br />A V2- crrymP MANTECA, 95337 <br />0-5, <br />CROSS STREET N. WALNUT <br />APIN PARCEL SIZE LAND USE APPLICATION# <br />OWNER NAME JOHN MILLER <br />O <br />uU,,jr, 7 PHONE 275.4449 <br />629 W YOSEMITE <br />cITY/sTATE/zIP MANTECA, CA 95337. <br />OWNERADDRESS <br />V <br />CONTRACTOR N & S IRRIGATION, INC PHONE 209.599.3456 <br />CONTRACTORADDRESs 215W. MAIN STREET <br />CITY/STATE/zip—RIPON CA. 95366 <br />SU6CONTitACTOR <br />PHONE <br />SUBCONTRACTOR ADDRESS <br />CITY/STATE/ZIP _ <br />LICENSE I C-57 I I C-61 I D-09 <br />�/ �+ <br />^Other C 1 0 NUMBER 662732 - ExPIRATION BATE 01 /31119 <br />r.... -d o -S v Y Township Ranae Section <br />NTENDED USE Domestic/Private i Inigation/Agricultural I I Industrial i7 Water Quality Monitoring i Soil SampliRM{Characterization <br />Public Water System <br />If different from Owner: Water bystern Nam L;ontaCt NaM or Phone Rumber <br />TYPE OF WORK New Well Replacement Well I i Well AlteratlONMOOIncation 1: Vmer <br />MonitoringWell(s) #of wells a SoilBoring(s) #ofbodrgs uGeotechnical #Of bo° tas <br />Out -Of -Service Well I Out -Of -Service Well Renewal i I Cross -Connection Repair <br />New PUMD X Pump Replacement I i Pump Repair I I Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method Mud Rotary Air Rotary Auger I Cable Tool I Push Point I Other <br />Proposed Well Depth ft Excavation in diameter i Open Bottom - Gravel Pack/Gravei Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched I Steel I I Plastic J Stainless Steel i I Other <br />Grout Seal Depth ft i_i Neat Cement (94 lb bag15-10 gal water) i I Sand Cement sack mix17 gal water <br />Bentonite (20% solids) ' I Other <br />Grout Placement Method I I Pumped ❑ Free Fall I I Other i Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor Other <br />Concrete Pedestal -Dimensions: Width ft Length It Thick in Christy Box -IStove Pipe <br />PUMP Submersibles Turbine i i Other. HP __1,5_ Pump Set__OD__ ft Standing Water Level 29 _ ft <br />1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAQ COUNTY O# DINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />Q.WFFENT D AClj1/E WITH THE f LIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />RKERS C MPEN ATION LAWS./ ' % <br />v <br />��JK°nR EP"'-� esl <br />Itko . Application Accepted By <br />Grout Inspection By <br />Pump inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />REQUIRED FOR INSPECTIIOON�S�- PLEASE CALL (209))99f53--7697 / <br />TITLELi�'1 —�--7/� DATE / <br />E,e RTMNT YSEE��P�N�LfY %��-'�'� <br />DaEte ���J��2L L—L Area��P Employee IDd� i <br />Date SPECIAL W@II Permit <br />Date 0 a • ❑ WAIVER Received <br />Date Constructed Well Depth ft <br />_Lh <br />M <br />EHD 43 -os WELL (PUMP PERMIT <br />413°/1 2 <br />