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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 /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> to <br /> JOB ADDRESS 17204 S.AUSTIN RD cITY21P MANTECA, 9533 m <br /> 0 <br /> CROSS STREET I O IISF PARCEL SIZEeU AND USE APPLICATION# m <br /> m <br /> OWNER NAME JOHN SEPHOS PHONE 209.471.4091 H <br /> OWNER ADDRESS 869 NORDIC PLACE CITYISTATE/ZIP MANTECA, CA. 95336 <br /> CONTRACTOR N &S IRRIGATION, INC PHONE 209.599.3456 <br /> CONTRACTOR ADDRESS 215 W MAIN STREET CITY/STATE/ZIP RIPON, CA, 95366 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY(STATE/ZIP <br /> LICENSE C-57 I 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 System Name ContaCt Name or Phone um r <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br /> Monitoring Wells) #of wells Soil Boring(s) #of Wrings Geotechnical #of bonngs A ME <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 E�VED/� <br /> Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other I C r <br /> Proposed Well Depth ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size-�c�in�d�am <br /> ieter 018 <br /> Conductor Casing in diameter / Conductor Casing Depth ft `"V�JOq <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched I Steel Plastic I Stainless Steel Other E �N C�VNTM <br /> Grout Seal Depth ft Neat Cement(94 lb bag/5-10 gal water) Sand Cement sack MENr <br /> Bentonite(20%solids) Other �T HT <br /> Grout Placement Method i 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___2Pump Set__BD ft 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 /> JO OUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> C RENT ND ACTI WITH E LIFORNIA C NTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WO ERS OMPEN ON LA S. <br /> tlm" <br /> U A OTICE REQUIRED FOR <br /> /INSPECTIONS <br /> y-PLEASE CALL(209)9§3-7697 <br /> SIGNED TITLE DATE <br /> N <br /> VVI E <br /> S <br /> I VIP_ <br /> 7777=- <br /> EP RTMENT U E N Y <br /> Application Accepted By a Date Area ` ( Employee ID#-140 <br /> Grout Inspection By 1 71 Date� SPECIAL WBII Permit <br /> Pump Inspection ByIAADate C WAIVER Received <br /> Soil Baring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Receivedck# Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Cas Remitted Service Re uest# <br /> zG6 �,b, lip <br /> EH D 43-06 WELL/PUMP PERMIT <br /> 4130/12 <br />