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I <br /> WELL/PUMP PERMIT <br /> e 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 /> rn <br /> JOB ADDRESS 4127 CARPENTER RD CITY/ZIP STOCKTON, 96215 <br /> �) <br /> 9 D <br /> CROSSSTREET MARIPOSA RD APN 1-1+ice; 4 7U PARCELSIZ4gLAND USE APPLICATION# <br /> OWNER NAME BRUCE WADE PHONE 652.0118 <br /> OWNER ADDRESS 4127 CARPENTER RD CITY/STATE/ZIP—STOCKTON, CA. 95215 <br /> CONTRACTOR N&S IRRIGATION, INC PHONE 209.599.3456 <br /> CONTRACTORADDRESs 215 W. MAIN STREET CITy/$TATE/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 Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization . <br /> Public Water System <br /> If different from Owner, Water System Name ContaCt Nam or Phone Number <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br /> Monitoring Well(s) 1*9k0(.%ells6, SoilBo4nO(s) #ofbunngs Ge �pjcal_ #of-borings <br /> , <br /> Out-Of-Service Well Out-Cif-Service Weil ReneAl Cross-Connection Repair <br /> New Pump X Pump Replacement Pump Repair I Raise Well Casing <br /> WELL CONSTRUCTION - <br /> Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other <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 Schad Steel Plastic Stainless Steel Other <br /> Grout Seal Depth ft Neat Cement(94/b bag/5-10 gal wafer) Sand Cement sack mixf7 gal water <br /> Begtanite(20%solids) Other <br /> Grout Placement Method Pumped Free Fall Other Retardant/Accelerator(name) ' <br /> PEDESTAL tl[1§typed DnllEr Pump Contractor Other <br /> Cb�jcr Pede 1 Dimensions:Width It Length ft Thick in Christy Box Stove Pipe <br /> PUMP XSubmersible Turbine Other HP__3_ Pump Set 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 /> JOAQUIN COUNTY RDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> UR ANDA VE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> VII KER COMP ATIONA 's9'" <br /> 0�1 D� ICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)9153-7697 <br /> RE $ tP TITLE ` `1 lam- DATE Z, 1-7 <br /> NJ� I A IVV � <br /> ENVIRO , <br /> PERA 11SEPVCH. <br /> l� <br /> RL <br /> ,ZS <br /> SAN JOAQUINC DEPARTMENTLYSE qNLY <br /> ENVIRON MENTAL -�- <br /> HEALTH DEPARTMFap�lation Accepted By Date Area �PECIAL <br /> Employee ID#� <br /> Grout Inspection By +Date ell Permit <br /> Pump Inspection By DateWAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received hec Amount Date PermiU Invoice# Well ID# <br /> Codes Info B Remitted Service Re uest# <br /> 110111 003-APY7 <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4/30112 <br />