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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-KFFUNDA13LE YtRMI T tALL(LUJ)J03-/ 071 FUK INJYtL; I IUNJ CAr'IKGJ T T tAK FKUM UA I t ISSUtU <br />JOB ADDRESS 23707 KINCAID RD <br />CITY/ZIIP/)MANTECA, 95337 <br />r1 <br />��/ <br />CROSS STREET W. RIPON RD APN <br />PARCEL SIZE .� / LAND USE APPLICATION # <br />Z� <br />OWNER NAME RYAN VAN DUYN <br />PHONE 209.840.1471 <br />OWNER ADDRESS 23707 KINCAID RD <br />CITY/STATE/ZIP MANTECA, CA. 95337 <br />CONTRACTOR N & S IRRIGATION INC <br />PHONE 209.599.3456 <br />CONTRACTOR ADDRESS 215 W. MAIN STREET <br />CITY/STATEIZIP RIPON, CA, 95366 <br />SUBCONTRACTOR <br />PHONE <br />)R ADDRESS CITY/STATE/ZIP <br />C-57 C-61 D-09 XOther C10 NUMBER 662732 EXPIRATION DATE 01/31/19 <br />GEOGRAPHICAL INFORMATION: Coordinates Y Township_ Range Sec <br />INTENDED USE Domestic/Pnvate Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br />Public Water Syslem <br />If different from Owner. Water System Name on a am or Pnone Numoer <br />TYPE OF WORK New Well Replacement Well <br />Monitoring Well(s) # of Wells <br />Out -Of -Service Well <br />New Pumo X Pump Replacement <br />Well Alteration/Modification Other <br />SoilBoring(s) 0 o borings Geotechnical <br />Out -Of -Service Well Renewal Cross -Connection Repair <br /># of borings <br />WELL I.ONSTRUCTION-Px�L�� N <br />Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other , 7 <br />Proposed Well Depth It 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 lb bag/5-10 gal water) Sand Cement sack man 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 __J— Pump Set Erin 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 />JOAQU OUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CU NT A D ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WO KERS C MPELTI'ON L W <br />MIN MUHO R V CE NOTICE REQUIRED FOR <br />�tINSPECTIONS <br />�]- PLEASE CALL (209) 953-7697 <br />SIGNED TITLE DATE p/l <br />D AR MENT U�Y <br />Application Accepted By ate <br />Grout Inspection By Date <br />Pump Inspection By � Date Q <br />Soil Boring Inspection By Date <br />COMMENTS <br />to <br />mm <br />0 <br />0 <br />0 <br />m <br />N <br />4 ?018 <br />C <br />h��:�� <br />Area Employee ID#=�`—IJ <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth ft <br />PE SC Received <br />Codes Info B <br />Chec Amount Date Permit/ Invoice # Well ID# <br />Remitted Service Request # <br />4A& <br />EHD 43-06 WELL /PUMP PERMIT <br />4/30/12 <br />