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1 <br />• WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />IVVN-tKEFUNDABLE VERMIT L;ALL (LUy) `Jb3-fbtff FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 3049 W. YOSEMITE AVE cITY/zIP LATHROP, 95330 <br />CROSS STREET MC KIN LEY APN PARCEL SIZE U i (� LAND USE APPLICATION # <br />OWNER NAME PETEEMEREDITH % PHONE 470.8042 <br />OWNERADDRESS 5432 ALMONDWOOD CITY/STATE/ZIP MANTECA CA, 95331 <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 <br />LICENSE C-57 C-61 D-09 <br />CITY/STATE/ZIP <br />XOther Ci10 NUMBER 662732 EXPIRATION <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township _ Range Section <br />NTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring i Soil Sampling/Characterization <br />Public Water System <br />If different from Owner: water system Name C.rt.ct Name or Phone Number <br />TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br />Monitoring Well s)___-_ # of wells Soil Borin s # of bonngs # of boring: <br />( g( ) Geotechnical <br />Out -Of -Service Well i Out -Of -Service Well Renewal i Cross -Connection Repair <br />New Pump A 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 Plastic Stainless Steel Other <br />Grout Seal Depth ft Neat Cement (94 Ib bagrS10 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 /2 Pump Set 6n ft Standing Water Level 267ft <br />1 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 AND ACTIVE ITH THE CA ORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />KERS OMPENSA N LAWS. <br />U�2A V E O CE REQUIRED FOR IN PP\ElC�Ig S, -,PLEASE CALL (209) 953-7697SIGNED TITLE DATE - Cl` <br />PAYM <br />REC'E <br />AUG A <br />5' djOAc <br />E"R( <br />�FALTH I <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />F! <br />p <br />to <br />D <br />A <br />N <br />3 <br />TMENTU E N L Y <br />—Date e/ Area mployee ID#A�~— <br />Date SPECIAL I Permit <br />DateWAIVER Received <br />Date Constructed Well Depth ft <br />PE SC <br />Codes Info <br />Receivedheck#/ Amount Date Permit/ Invoice# WellID# <br />B Remitted Service Request # <br />• <br />EMD 43-06 WELL /PUMP PERMIT <br />4130/12 <br />