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' t 4 Z�rkrw,� 5 uk^ <br /> WELUPUMP 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 /> JOB ADDRESS 18082 VAN ALLEN RDWclTvrzlP ESCALON 95320 <br /> Cie <br /> ]� � <br /> CROSS STREET HY 120 APN�i yPARCEL SIZE�.1 lJ.�J LAND USE APPLICATION# <br /> OWNERNAME BOB MATHIAS PHONE 209.838-7463 <br /> OWNER ADDRESS 17327 S.VAN ALLEN RD CITY/STATE21P ESCALON,CA 95320 <br /> CONTRACTOR N&S IRRIGATION, INC PHONE 209.599.3456 <br /> CONTRACTOR ADDRESS 215 W. MAIN STREET CITY/STATE21P RIPON CA.95366 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATEIZJP <br /> LICENSE I C-57 C-61 i D-09 XOther C10 NUMBER 662732 EXPIRATIONDATE 01/15 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br /> INTENDED USE XDomesticlPrivate Irrigation/Agricultural -Industrial C Water Quality Monitoring F- Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owrrerwater system Name L;ontact Name or Prione Number <br /> TYPE OF WORK _New Well Replacement Well L Well Alteration/Modification L Other <br /> .j Monitoring Well(s) #of wells L Soil Boring($) #of borings L Geotechnical #of borings <br /> Out-0f-Service Well ' <br /> Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pum X Pum Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary I Auger Cable Tool 1 Push Point Other <br /> Proposed Well Depth ft Excavation in diameter I Open Bottom P Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth It <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched L Steel F Plastic C Stainless Steel '._Other <br /> Grout Seal Depth ft Neat Cement(94 lb bag/5-10 gal water) Sand Cement sack mixf7 gal water <br /> -1 Bentonite(20%solids) Other <br /> Grout Placement Method ❑Pumped _;Free Fall I-Other F Retardant/Accelerator(name) <br /> PEDESTAL Installed By J Driller Pump Contractor L Other <br /> 1 Concrete Pedestal-]Dimensions:Width ft Length ft Thick in ❑Christy Box fl Stove Pipe <br /> PUMP XSubmersible-1 Turbine J Other HP 3 Pump Setup_ft Standing Water Level 76 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 /> CTWEITY AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> RKERS OMP[ <br /> MP ATIO S. <br /> IM��Mf U A NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-76697 <br /> SIGNE TITLE DATE `J <br /> N RFcF FNr <br /> s E <br /> Ew,'`0''a� C?41� <br /> C E } <br /> JAN 0 6 26? <br /> RONMENTAL HEALTH <br /> CRMITISERWCES <br /> 13-EP RTMENTIU SE ONLY }} (��jj��J <br /> Application Accepted Date Area e _ Employee ID#/A�DU1Z'J <br /> Grout Inspection By Date ,' SPECIAL Well Permit V <br /> Pump Inspection By tate I I�(�1/, WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth It <br /> COMMENTS <br /> PE Sc Received Che Amount Date Permit/ Invoice# WeI11D# <br /> Codes Info B Remitted Service Request# <br /> i)Gba4�S ' �n 91 t058ZV4N0N2-qLP <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4/30/12 <br />