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WELL/PUMP PERMIT <br /> • ' SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)466-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> rn <br /> JOB ADDRESS 10551 E. SOUTHLAND RD. CITY/ZIP MANTECA, 95336 m <br /> -�-CROSS STREET AUSTIN RD APN" .idyA 47Z- PARCEL SIZE LAND USE APPLICATION m <br /> OWNER NAME RAMON MARTINEZ EsnearYadlZU PHONE 209.284.9304 <br /> R2OWNER ADDRESS 10551 E. SOUTHLAND RD. CITY/STATE/ZIP MANTECA, CA 95336 <br /> J 5 CONTRACTOR N&S IRRIGATION, INC PHONE 209.599.3456 <br /> Zw CONTRACTOR ADDRESS 215 W MAIN STREET CITY/STATE/ZIP RIPON. CA. 95366 <br /> 4"I SUBCONTRACTOR PHONE <br /> Lj Q SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> Lu <br /> Uj (L LICENSE C-57 C-61 D-09 XOther C10 NUMBER 662732 EXPIRATION DATE 01/31/19 <br /> LI J GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section <br /> INTENDED USE X Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner. water system Name contad Name or Prone Numoer � <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other �LA%f r <br /> Monitoring Well(s) #of wells Soil Boring(s) #of borings Geotechnical #of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump X Pump Reolacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION JJ 4`J}7`Q�11��9 <br /> Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Well Depth ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size in <br /> Conductor Casing in diameter / Conductor Casing Depth It <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched Steel i Plastic I Stainless Steel I Other <br /> Grout Seal Depth ft Neat Cement(94 Ib bag/5-10 gal water) Sand Cement sack mix/7 gal water <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__2 _ Pump Seth_ft Standing Water Level__A3__ft <br /> I CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> AQUIN C UNTY DINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> RRENT A D AC WIT TH ALIFORNIA C TRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WO RS COMPS S T10N AW . <br /> I U 4 0 R 13 IANCE OTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)_953-7697 <br /> SIGNED TITLE I—/\A�tj A (�I.�� DATE <br /> N <br /> E <br /> S <br /> EPLRTMENT U E 0 <br /> 7 LY <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 heck# Amount Date Permit/ <br /> Invoice# Well ID# <br /> Codes Info B Remitted Service Re uest# <br /> 2 CO I <br /> EMD 43-06 WELL/PUMP PERMIT <br /> 4/30/12 <br />