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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 /> in <br /> JOB ADDRESS 12100 GRAVES RD W /2 q CITY/ZIP MANTECA 95336 <br /> 0 <br /> CROSSSTREET AUSTIN RD APN Z,2j'0 G O] PARCEL SIZE2-0 LAND USE APPLICATION# D <br /> OWNER NAME BUD TRAVAILLE — R DSA—fl6f-W S 4. <br /> PHONE 541.7777 <br /> OWNER ADDRESS 12100 GRAVES 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 i I C-57 n C-61 I 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 D Industrial ❑Water Quality Monitoring n Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water System Name L;ontaCt Name or Phone Numn.r <br /> TYPE OF WORK New Well _ Replacement Well 17 Well Alteration/Modification n Other <br /> Monitoring Wells) #Of wells I I Soil Boring(s) #of bodngs lI Geotechnical #of bodngs <br /> Out-Of-Service Well I I Out-Of-Service Well Renewal n Cross-Connection Repair <br /> New Pump X Pump Replacement I I Pump Repair n Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method - Mud Rotary Air Rotary . Auger n Cable Tool It Push Point I- Other <br /> Proposed Well Depth ft Excavation in diameter J Open Bottom -1 Gravel Pack/Gravel Size in diameter <br /> - Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Schad J Steel F1 Plastic n Stainless Steel n Other <br /> Grout Seal Depth ft I I Neat Cement(94 lb bag/5-10 gal water) U Sand Cement sack mixf7 gal water <br /> - Bentonite(20%solids) U Other <br /> Grout Placement Method ❑Pumped n Free Fall D Other J Retardant/Accelerator(name) <br /> PEDESTAL Installed By I Driller a Pump Contractor Other <br /> Concrete Pedestal-Dimensions:Width ft Length It Thick in Christy Box -1 Stove Pipe <br /> PUMP Submersible[ Turbine n Other HP__2 _ Pump Sel___&�_ft 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 /> JOA UNTY O NANCES, STATE LAWS, AND CJLES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> C RENT A ACT E WITH T C LIFORNIA C "ACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> W KERS CO PEN A ON LAW . <br /> I U 2 H UR D / N ICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209))9513-7 7 <br /> SIGNED TITLE r`� "A`�—" DA7E _( - �—I <br /> N <br /> VVI E <br /> S <br /> iEPARTMENT USE ONLY <br /> Application Accepted By n Date Area I Employee ID# A ML7 <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date i ❑ WAIVER Received <br /> Soil Boring Inspection By Dale Constructed Well Depth It <br /> COMMENTS t C4 11 C1uJ �r' Y hP Ufa ;nSnr"r a;un, (mule !uCYf,- <br /> PE SC Received Chec Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B ash Remitted S rvic Re uest# <br /> 9311 I oSv ,P589 <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4/30/12 <br />