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y <br /> 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 /> N <br /> JOB ADDRESS 10294 JEANE RD cITY21P MANTECA 95336 n <br /> 0 <br /> CROSS STREET AUSTIN RD AP PARCEL SIZE LAND USE APPLICATION# m <br /> N <br /> OWNER NAME LEO DEGROOT PHONE 823.1644 "• <br /> OWNERADDRESS 10294 JEANE RD CITY/STATE/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 CIO 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 OwnerWa er ys em Name C.nt.Ct Name or Phone Nunnb.l <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells Sail Boring(s) #or borings Geotechnical uof bo rigs <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 <br /> Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Well Depth ft Excavation in diameter i Open Bottom Gravel Pack/Gravel Size N CO <br /> Conductor Casing in diameter / Conductor Casing Depth It A1TH DE F/V'7k y <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad Steel Plastic Stainless Steel Other Rr <br /> Grout Seal Depth ft Neat Cement(94 lb bag/5-10 gal water) Sand Cement sack mix/7 gal water r <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__1,5_.5 Pump Set _It 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 /> JOAQUIN COUNTY,ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CU AND IVE WIT T E CALIFORNI CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> RKER OM NSA A <br /> MINIM 2 OR A NOTICE REQUIRED FOR INSP (`TONS-77PLEASE CALL(209►�63^-76 7 <br /> SIGNED \ TITLE "� "`V DATE `/ [ <br /> N <br /> E <br /> S <br /> r%Ir low 11 ff 111111% <br /> ENVI r <br /> v <br /> P <br /> EPRTMENTT UJ <br /> Application Accepted By Date Area Employee ID# <br /> Grout Inspection By 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 ec Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B sh Remitted Service Re uest# <br /> 312 i bu�oo�xVco <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4/30/12 <br />