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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 /> iC y <br /> JOB ADDRESS 5880 FIG RD CITY/ZIP MANTECA, 95336 D <br /> 0 <br /> CROSS STREET UNION RD. APN 22 bo 5007 PARCEL SIZE 1.2 LAND USE APPLICATION# m <br /> OWNER NAME HERB RAWLINS I 66� K J j MJ ROW)//7S I(� PHONE 823.5436 w <br /> OWNER ADDRESS 5841FIG RD CITY/STATE/ZIP MANTEACA. CA, 95336 <br /> CONTRACTOR N&S IRRIGATION, INC PHONE 209.599.3456 <br /> CONTRACTOR ADDRESS 215 W MAIN STREET CITY/STATEIZIP 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 Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner Water System Name Contad N.m.or Phone N.Mbe, <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br /> Monitoring Wells) #of wells Soil Boring(s) S of borings Geotechnical #of borings <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 V <br /> FC�'� <br /> Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other `c �D <br /> Proposed Well Depth ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size in clienta <br /> Conductor Casing in diameter / Conductor Casing Depth ft �� O D <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other a ?O,f? <br /> Grout Seal Depth ft Neat Cement(94 lb bag/5-10 gal water) Sand Cement sack mix,7 gal Qjj/N v <br /> Bentonite(20%solids) Otherkry <br /> Grout Placement Method Pumped Free Fall Other Retardant/Accelerator(name) H Fpq�NT� <br /> PEDESTAL Installed By Driller Pump Contractor Other MFNT <br /> Concrete Pedestal Dimensions:Width ft Length ft Thick in Christy Box Stove Pipe <br /> PUMP XSubmersible Turbine Other. HP 2 Pump Set 60 ft Standing Water Level 35 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 /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> W S COMP ATION LAWS. <br /> IM H NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209 53-769 <br /> SIGNED �������� TITLE �� DATE <br /> N <br /> IN E <br /> S <br /> RECis <br /> JAN <br /> ENVIRONM <br /> PERMI �D <br /> EPLRTMENT �SyE ONLY <br /> Application Accepted By Al ate ! a Area Employee ID#� <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By v Date 1 10 <br /> — WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check Amount Date Permit/ Invoice# WellID# <br /> Codes Info B ash Remitted Service Request# <br /> AH <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4/30/12 <br />