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� 1 <br /> WELL/PUMP PERMIT <br /> SAN JOAOUIN 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 30085 S. KOSTER RD CITY/ZIP TRACY, 95304 m <br /> D <br /> CROSSSTREET DURHAM FERRY RD APN }}-D PARCEL SIZE LAND USE APPLICATION# <br /> OWNER NAME - RE$ MC CREARY /l 1 r I wI PHONE 607.8775 <br /> OWNER ADDRESS 30085 S. KOSTER RD CITY/STATE/ZIP <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 CITY/STATE/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 Rangi Section_ <br /> INTENDED USE XDomesticlPrivate Irrigation/Agricultural i Industrial Water Quality Monitoring i Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water System Name contact Name or Phone Num r <br /> TYPE OF WORK New Well Replacement Well Well Alteralion/Modifiration Other <br /> Monitoring Well(s) #of wells Soil Boring(s) #of bomgs Geotechnical #of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump X Pump 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 It Excavation in diameter 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 Sched Steel 1 Plastic 1 Stainless Steel i Other <br /> Grout Seal Depth It Neat Cement(94 lb 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 ft Length ft Thick in Christy Box Stove Pipe <br /> PUMP XSubmersible Turbine Other HP 1.5 Pump Set 60 ft Standing Water Level 14 ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOA OUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> RENT D ACTIV H THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> RKERS C <br /> IS <br /> MPEN ITLAW A j <br /> M 2 UR D E NOTI REQUIRED FO.�R�ItNnS_PE1C'TIONS-PLEASE CALL(209))953-7697^/ <br /> SIGNED TITLE X \R7kr Kl�� _ DATE <br /> N <br /> E <br /> S <br /> R C1047y ISAWE <br /> JOAnUF E <br /> es"n N <br /> HEA1-TM DE <br /> (� T M ENT E N L Y '�L��� <br /> Application Accepted By ate `/ Area Employee ID#� <br /> Grout Inspection By Date I Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC ReceivedChec Amount Date Permit/ Invoice# WellID# <br /> Codes Info B ash Remitted Service Request# <br /> ,RIZ06 7 <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4/30/12 <br />