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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)466-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 10700 E. LOUISE AVE cITYmP MANTECA, 95336 <br /> D <br /> C 0 <br /> CROSS STREET AUSTIN RD APN PARCEL SIZE s�• AND USE APPLICATION# a <br /> OWNER NAME BETTENCOURT&BORGES I6r:*,ZZhYA-s PHONE 823.9202 <br /> OWNER ADDRESS 23675 S.AIRPORT RD 'I lou i1��✓ '�� 15STATE/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 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 i Irrigation/Agricultural n Industrial ❑Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If different from Ownar: a er ystem Nam Con a ame or one um r <br /> TYPE OF WORK New Well _ Replacement Well Well Alteration/Modification .i Other A�� <br /> Monitoring Wells) #of wells i Soil Boring #of borings s) i!Geotechnical #of borings <br /> Out-Of-Service Well i Out-Of-Service Well Renewal r!Cross-Connection Repair C�I�� <br /> New Pum X Pum Replacement Pum Repair Raise Well Casing <br /> WELL CONSTRUCTION 2 <br /> Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point r Other 222018 <br /> Proposed Well Depth It Excavation in diameter 7 Open Bottom i Gravel Pack/Gravel Size in lb1�t <br /> Conductor Casing in diameter / Conductor Casing Depth ftF/V Qu/AJ you <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched I Steel D Plastic D Stainless Steel ❑Other HFA CNME/� NTy <br /> Grout Seal Depth ft Neat Cement(94 Ib bag/5-10 gal water) a Sand Cement sack mix17 gal water DEPARTMENT <br /> Bentonite(20%solids) _Other <br /> Grout Placement Method Pumped i Free Fall i i Other J Retardant/Accelerator(name) <br /> PEDESTAL Installed By i. Driller i i Pump Contractor Other <br /> Concrete Pedestal-Dimensions:Width ft Length It Thick in - Christy Box Stove Pipe <br /> PUMP XSubmersible:. Turbine - Other HP�_ Pump SetIt 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 /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURR AND ACTT WITH HE ALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> W ERS OMPEN ON LA S. <br /> H U A V E TICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-769Z <br /> SIGNED TITLEDATE <br /> N 1 <br /> E <br /> S <br /> REC <br /> MAR <br /> ENVIROMMEW <br /> PERMIT <br /> Y1AE P T M ate S'�Y � %'/' <br /> Application Accepted By Date � Are a_ %/-/"/ Employee ID#/"ff-V <br /> Grout Inspection By T77� Date SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received <1 ec Amount Date Perm t/ Invoice# WeIIID# <br /> Codes Info B ash Remitted Service Re uest# <br /> 4,177 Wpaa� <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4/30/12 <br />