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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 /> to <br /> JOB ADDRESS 791 W, LOUISE AVE CITY/ZIP MANTECA 95336 n <br /> 0 <br /> CROSSSTREET N. UNION RD. _APN PARCELSIZE LAND USE APPLICATION# m <br /> N <br /> OWNER NAME WALTER SILVA PHONE 239.4017 y <br /> OWNER ADDRESS 791 W. LOUISE AVE CITY/STATEIZIP 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 CITYISTATE/ZIP <br /> LICENSE C-57 C-61 D-09 XOther C 1 0 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 bystem Name on a ame or Phane Number <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other � eO,�N• <br /> Monitoring Wellg #of borings s) #of wells Soil Boring(s) Geotechnical #of bonngs <br /> Out-Or-Service VVell Out-Of-Selvica'Vlull Renewal Cross-Connection Repair Ol9T <br /> New Pum X Pum Replacement Pum Repair Raise Well Casingl•I 4 20`/8 <br /> ' <br /> WELL CONSTRUCTION ' J 7 <br /> Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other V �qQ C <br /> Proposed Well Depth ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size 11FE EN�.L TY <br /> Conductor Casing in diameter / Conductor Casing Depth ft T <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other MFNT <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 It Length It Thick in Christy Box Stove Pipe <br /> PUMP XSubmersible Turbine Other HP__I- Pump Set___611 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 /> JOAQUI OUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CUR NT ND ACTIVE WITH THE CALIFORN CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WO ERS C MPE ATIO LA S. <br /> I U 4 A V E NOTICE REQUIRED FOR INSPECTIONS PLEASE CALL(209)9,53-7 697 <br /> SIGNED TITLE DATE <br /> N <br /> E <br /> S <br /> All <br /> AR MENT U E O Y <br /> Application Accepted By ate Area ployee 011/ <br /> Grout Inspection By Date WSPECIAL Well Pertllit <br /> Pump Inspection By Date f WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received h Amount Permit/ <br /> Codes Info B Cas emitted Date S ice Re uest# Invoice# Well 10# <br /> �1� <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4/30/12 <br />