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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 PER P <br /> T CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> to <br /> JOB ADDRESS 5715 NORHTLAND RD clTYlz,P MA TECA, 95336 m <br /> A <br /> CROSS STREET S FRONTAGE APN 1-010O ARCELSIZE0S—LAND USE APPLICATION# <br /> OWNER NAME MILDRED WHITE Tr PHONE 403.9065 y <br /> OWNER ADDRESS 5715 NORHLAND RD. CITY/STATE/ZIP MANTECA, CA 95336 <br /> CONTRACTOR N &S IRRIGATION, INC PHONE 209.599.3456 <br /> CONTRACTORADDRESs 215 W. MAIN STREET CITY/STATE21P RIPON CA. 95366 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE '_i 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 i Irrigation/Agricultural Industrial Water Quality Monitoring i Soil Sampling/Charactenzation <br /> Public Water System <br /> If different from Owner Water System Nam Contact Nam or Phone Number <br /> TYPE OF WORK New Well Replacement Well :Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells Soil Boring(s) x of borings Geotechnical a of bonngs <br /> Out-Of Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump X Pump Replacement Pump Repair Raise Well Casio <br /> WELL CONSTRUCTION <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 diameter <br /> Conductor Casing in diameter / Conductor Casing Depth It <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel C Other <br /> Grout Seal Depth ft Neat Cement(94 Ib bag15-10 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___J_ Pump Set It Standing Water Level It <br /> I HE EBY CERTIFY AT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> AQU COUNTY O DINAN EnDNAC <br /> TE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT NO A TI WIT TLIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS OMP NS TION L WIMU O TICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-76 <br /> SIGNE TITLEQ <br /> �Iv\'\^' '`b DATE v i C <br /> N <br /> S E CEIV . <br /> �AY 0 3 2011 <br /> ONMENTAL HEALTH <br /> RMIT/SERVICES <br /> PAYME <br /> RECEIV <br /> ' MAY 09 <br /> SAS JOAQUI'NCc DE ARTMENT USE ONLY <br /> ENVIRONM'ch'a' � ^,f ,t <br /> yEpLTN OF" Application Accepted By Date Area Employee ID#%{/K�(f,�7+�/(� J <br /> Grout Inspection By Date I i SPECIAL WBII Permit <br /> Pump Inspection By Date C WAIVER Received <br /> Soil Boring In clion By /DEP Constructed Well Depth ft <br /> COMMENTS 11 <br /> PE SC Received Check#V Amount Date Permit/ Invoice# Well ID# <br /> Codes Info Remitted Service Request# <br /> gis 0-190 vqft_M3y <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4/30112 <br />