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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 />NUN-KEFUNDAt1Lt YtKMII ILUt7) Z10 i-yCJ/ FUR INSYtL; IIUNS <br />tArIKtJ "1 TLAR I -RUM UA It ISSUtU <br />JOB ADDRESS <br />^ �/ / `B /A'L`L- <br />VV( <br />_� 3 �- V V l `�"_` V W A-Vtf— <br />CITY/ZIP <br />MANTECA, 95337 <br />CROSS STREET <br />OAK ST. APN <br />jPARCEL SIZE.O GLAND <br />USE APPLICATION # <br />OWNER NAME <br />MEYER'S REALTY <br />PHONE 209.239.1374 <br />OWNER ADDRESS <br />370 N MAIN <br />CITY/STATE/ZIP <br />MANTECA, CA 95336 <br />CONTRACTOR <br />N & S IRRIGATION, INC <br />PHONE 209.599.3456 <br />CONTRACTOR ADDRESS 215 W MAIN STREET <br />CITY/STATE/ZIP RIPON, <br />CA. 95366 <br />SUBCONTRACTOR <br />PHONE <br />SUBCONTRACTOR ADDRESS <br />LICENSE C-57 C-61 D-09 <br />CITY/STATE/ZIP <br />XOther C 1 0 NUMBER &B2Z32 EXPIRATION DATE 01/31/19 <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br />NTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System <br />If different from Owner Water System Name on a ame or one um er <br />TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br />MonitoringWell(s) #of wells SoilBohng(s) #of borings Geotechnical #ofborings <br />Out -Of -Service Well Out -0f -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 in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter_ in Thickness/Gauge/ASTM Sched Steel i Plastic Stainless Steel Other <br />Grout Seal Depth ft Neat Cement (94 Ib bagl5-10 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 ft Length ft Thick in Christy Box Stove Pipe <br />PUMP XSubmersible Turbine Other HP 1 Pump Set 40 ft 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 />JO NTY ORANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />C RRE;RSCOM <br />ACTIV ITH T E IFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />W ENS TI N LA S. <br />UM 4 R D A CE REQUIRED FOR INSPECTIONS- PLEASE CALL (2091953-7697 <br />SIGNED TITLE I�� "" ` " "� DATE t 0 <br />p,gMEN <br />RECEfVF <br />� OCS 2 7 <br />�M/IROHM <br />HEpyTFi DEPT <br />N <br />1�4 <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />I I I I I I I I I I I I I I I I I I I I I I I I I I I I <br />DEPARTMENT USE Y <br />Date 123 / Area Employee ID#_� <br />Date ell Permit <br />Date — WAIVER Received <br />Date Constructed Well Depth ft <br />PE <br />Codes <br />SC Received heck <br />Info By as <br />Amount <br />Remitted <br />Date <br />Permit/ Invoice # Well ID# <br />Service Request # <br />EHD 43-06 WELL /PUMP PERMIT <br />4/30/12 <br />