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r (21 <br /> z <br /> 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 /> JOB ADDRESS 16772 S. AUSTIN RD CITY/ZIP MANTECA, 95336 A <br /> r 0 <br /> CROSS STREET E. LOUISE AVE APN PARCEL SIZE LAND <br /> LAND USE APPLICATION# m <br /> OWNER NAME ERIC ISBELL �.r l c T Cru UW10 C7� I—!` PHONE 609.2727 <br /> OWNER ADDRESS 16772 S. AUSTIN RD CITYISTATE21P MANTECA, CA 95336 <br /> CONTRACTOR N &S IRRIGATION, INC PHONE 209.599.3456 <br /> CONTRACTOR ADDRESS 215 W. MAIN STREET CITYISTATE/ZIP RIPON. CA. 95366 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATE/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/Pdvate Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water System Name one Name or Phone Number <br /> TYPE OF WORK New Well Replacement Well i Well Alteration/Modification Other <br /> MonitoringWell(s) #of wells SoilBoring(s) #oftodngs Geotechnical #oftorinoy <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump XPump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary Auger Cable Tool -Push Point Other <br /> Proposed Well Depth ft Excavation in diameter I Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Schad _i Steel ;_i Plastic n Stainless Steel I I Other <br /> Grout Seal Depth _ft i Neat Cement(94/b bag/5-10 gal water) i Sand Cement sack mixR 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 XSubmersiblei Turbine ..Other HIP_ Pump Set 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 /> RRMT AND AC VE WITH TH CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> ORKER�COMPE ATION AW . <br /> U 4 HO R D A OTICE REQUIRED FOiRAINSPECTIyONS-PLEASE CALL(2091)9i53-J7697 <br /> SIGNED/ TIRE 1't-' lV DATE �li��l <br /> N <br /> E <br /> S <br /> �S% t 'n <br /> My 0 13 201? <br /> PAYMEN <br /> REE Np4ENTAL HEALTH <br /> N9i7/SERVICES <br /> MAY I 12 jail -Z <br /> y,N JoAnUIN G <br /> El,MRONME A <br /> HEAL-TN DEPAR M <br /> E PyA R T M E N T USE N L Y <br /> f <br /> Application Accepted By Date Area Employee ID#� <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By TAraS4A&4LL Date _ WAIVER Received <br /> Soil Boring Inspe on E# Date Constructed Well Depth ft <br /> CO ME TS <br /> L' L tlir .y <br /> PE SC Received Ch Amount Date PermiU Invoice# Well ID# <br /> /I <br /> Codes Info <br /> ash Remitted Service Request# <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4/30/12 <br />