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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 FQWNSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> rn <br /> JOB ADDRESS 13954 SOUTH FRONTAGE HWY 99 CITY/ZIP MANTECA, 95336 m <br /> CROSSSTREET NORTHLAND APN PARCEL SIZE LAND USE APPLICATION# <br /> OWNER NAME LESLIE HARRINGTON PHONE 209.815.0512 y <br /> OWNER ADDRESS 13954 SOUTH FRONTAGE HWY 99 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 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 bystern Name uontact Name or one Number <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other ��• <br /> Monitoring Well(s)_ #of wells Soil Boring(s) #of borings Geotechnical ft of borings �/�® <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair �/�P <br /> New Pump X Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION A., 4 7 2018 <br /> -pAY <br /> Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other ` �JnF U/N <br /> Proposed Well Depth ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size N '19h1E1� NM�OU/V�r <br /> Conductor Casing in diameter / Conductor Casing Depth ft LTH PARTM <br /> Well Casing Diameter—in Thickness/Gauge/ASTM Sched Steel i Plastic -i Stainless Steel I Other ENT <br /> Grout Seal Depth ft Neat Cement(94/b 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 Pump Set 80 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 ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CU AND A IVE W TH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> ORKERS OMP SATIO L S. <br /> IM 4 H U�A�ft4D1 NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-76997 )` <br /> SIGNED ll �/VV��// TITLE �7\"�' `v�'�---� DATE (�.17. <br /> V <br /> N <br /> E <br /> S <br /> ,J <br /> P A R M E N T U O L - / ` <br /> Application Accepted + Date /^S� Area Employee ID#�� <br /> Grout Inspection By Date t I. SPECIAL well Permit <br /> Pump Inspection By Date Q ( E WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth It <br /> COMMENTS <br /> PE SC Received Chec Amount Date Permit/ Invoice# WellID# <br /> Codes Info B sh Remitted Service Re uest# <br /> EHO 43-06 WELL/PUMP PERMIT <br /> 4130/12 <br />