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4(41 39-Cl- Cl OCj-\ <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 /> y <br /> JOB ADDRESS 13850 JACK TONE RD CITY/ZIP MANTECA, 95336 n <br /> D o <br /> CROSS STREET LONE TREE A4,1621"45D <br /> / PARCEL SIZE LAND USE APPLICATION# _ m <br /> OWNER NAME MAX SLAYTER 14LAM0, PHONE 234.1121 <br /> OWNER ADDRESS 13850 JACK TONE RD CITY/STATE/ZIP MANTECA, CA 9533 AP0J' <br /> CONTRACTOR N&S IRRIGATION, INC PHONE 209.599.3456 ^� <br /> CONTRACTOR ADDRESS 215W. MAIN STREET CITY/STATE/ZIP RIPON. CA, 95366 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C-57 L;C-61 D-09 XOther C10 NUMBER 662732 EXPIRATION DATE-0 1/31/19 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br /> INTENDED USE Domestic/Private I Irrigation/Agricultural n Industrial =1 Water Quality Monitoring i i Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water System Name on a ame or ane um er <br /> TYPE OF WORK New Well Replacement Well _1 Well Alteration/Modification i Other <br /> Monitoring Wells) #of wells i Soil Boring(s) #of borings i.Geotechnical #of borings <br /> Out-Of-Service Well a Out-Of-Service Well Renewal i 1 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 ft Excavation in diameter i Open Bottom 7 Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched _j Steel n Plastic CI Stainless Steel !7 Other <br /> Grout Seal Depth ft Neat Cement(94/b bag/5-10 gal water) I Sand Cement sack mixf7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped .Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By I. Driller !Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width ft Length ft Thick in Christy Box Stove Pipe <br /> PUMP XSubmersiblel Turbine Other HP__1,5—-5 Pump Set 1 QI ft Standing Water Level-___4n__ft <br /> 1 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 /> T AND TIVE WITH E CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> ORKE CO NSATIO L <br /> NI 4 H V OTICE REQUIRED FOR INSPECTIONS--PLEASE CALL(209)9A3-707 <br /> SIG D TITLEDATE <br /> N <br /> WI <br /> S EI Haw <br /> "CE-IVEM <br /> AR 2 3 2011 <br /> ONMENTAL HEALTH <br /> 10 14 11 RM17_/SERW,ES <br /> 84 Y41, <br /> 47- <br /> it it it MqR?X20 y <br /> 4,1 Rp CO <br /> E4L 7) QFPM�� 4 <br /> P RTMENT U E NLY MINT <br /> Application Accepted By EDate 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 C ChecW Amount Date Permit/ <br /> Codes WeIIID# <br /> Codes Info B Remitted Service Request# <br /> J101 <br /> & 3idn S 77055 W 1(Q <br /> EHD 43-05 WELL/PUMP PERMIT <br /> 4130/12 <br />