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1_11_1--( <br /> WELL/PUMP PERMIT <br /> s <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 /> D <br /> JOB ADDRESS 16634 LAWRENCE RD CITY/ZIP ESCALON 95320 m <br /> {� D <br /> CROSS STREET ARTHUR RD APN Z7 q-b co-d Z PARCEL SIZEZ431LAND USE APPLICATION# <br /> OWNER NAME MARLENEENOS �JlIDS,C',LA'()LQ/} ��_ T� PHONE 209.838.7539 <br /> OWNER ADDRESS 16634 LAWRENCE RD CITY/STATE/LP ESCALON, CA 95320 <br /> CONTRACTOR N&S IRRIGATION, INC PHONE 209.599.3456 <br /> CONTRACTOR ADDRESS 215 W. MAIN STREET _ cITY/sTATE21PRIPON CA. 95366 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/LP <br /> LICENSE "1 C-57 -1 C-61 -1 D-09 XOther C10 NUMBER 662732 EXPIRATION DATE 01/15 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br /> INTENDED USE Domestic/Private "'Irrigation/Agricultural Industrial Water Quality Monitoring 0 Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner Water System Name Contact Name or Phone Number <br /> TYPE OF WORK -,New Well Replacement Well Well Alteration/Modification Other <br /> Monitoring Wells) #of wells Soil Boring(s) if of borings L Geotechnical #of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal C Cross-Connection Repair <br /> New Pump xi Pump Replacement Pump Repair r Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary I Air Rotary l Auger Cable Tool . Push Point Other <br /> Proposed Well Depth ft Excavation in diameter I Open Bottom I Gravel Pack/Gravel Size in diameter <br /> _I Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Schad ❑Steel G Plastic G Stainless Steel ❑Other <br /> Grout Seal Depth ft Neat Cement(94 lb bagV5-10 gal water) C Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method -1 Pumped Free Fall n Other F Retardant/Accelerator(name) <br /> PEDESTAL Installed By i Driller a Pump Contractor LJ Other <br /> Concrete Pedestal lDimensions:Width ft Length ft Thick in n Christy Box Cl Stove Pipe <br /> PUMP XSubmersible 7 Turbine 7 Other. HP 1 Pump seI 122 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 /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT.,AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> Vftl�KERS MPENs ON LAWS. PA <br /> IN U 4 U A A CE OT EQUIRED FO INSPECTIONS-PLEASE CALL(209)L953 7��/ -/ R Cz��r <br /> SIGNED TITLE DATE S2 <br /> N �N ��?017 <br /> S EV Ar 16 <br /> wa kTMevr <br /> CEIVED <br /> JAN 0 6 2011 <br /> IROWENTAL HEALTH <br /> ERMIT/SERMES <br /> EP RTMENT USE ONLY <br /> Application Accepted By AIA _ Date_ �� Area 4qq Employee ID# Dbi� <br /> Grout Inspection By Date I I ( SPECIAL Well Permit r <br /> Pump Inspection By Date 0 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Chec Amount Permit/ <br /> Codes Info B ash Remitted Date Service Re uest# Invoice# Well <br /> RA 01;9 z M 40 Io I) SRQQ-7m5$1 <br /> EHD 47-06 WELL/PUMP PERMIT <br /> 4/30/12 <br />