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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 PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> y <br /> JOB ADDRESS 16772 S. AUSTIN RD �J��t^' /` CITY/ZIP MANTECA, 95336 n <br /> CROSS STREET E. LOUISE AVE APN(��TV /' V/�^ PARCEL SIZE LAND USE APPLICATION# <br /> OWNER NAME ERi6 ISBELL f�IG I C-1a,t-i,G PHONE 609.2727 •`"• <br /> OWNER ADDRESS 16772 S.-.AUSTIN RD CITY/STATE/ZIP MANTECA, CA 95336 <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_ Range Section <br /> INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water System Name Contact ame or Prone um r <br /> TYPE OF WORK New Well Replacement Well :1 Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells _J Soil Boring(s) #of bonngs Geotechnical #of bodngs <br /> XOut-Of-Service Well ❑Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement n Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> F Drilling Method Mud Rotary Air Rotary Auger Cable Tool - Push Point Other <br /> if Proposed Well Depth ft Excavation in diameter 7 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 :1 Steel 7 Plastic Stainless Steel I Other <br /> Grout Seal Depth ft Neat Cement(94 Ib bag/5-10 gal water) Sand Cement sack mixf7 gal water <br /> Bentontte(20%solids) Other <br /> Grout Placement Method Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> f Concrete Pedestal Dimensions.Width ft Length ft Thick in Christy Box Stove Pipe <br /> PUMP XSubmersible Turbine Other HP Pump Set ft Standing Water Level it <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 /> WO COMPENSATIONAWfDj <br /> ! MI M � ORNCS ICE REQUIRED FOR <br /> /INSPECTIONS <br /> �-/PLEASE CALL(209)953-7(6(97 <br /> SIGNED \\ / TITLE"1"rl r ''r 1� 1/_ - DATE <br /> N <br /> E • <br /> S <br /> INA <br /> arr s <br /> NN vNE 1 ENTAL HEALTH <br /> E /OERVIFS <br /> 501 <br /> J0 RONtIENTME, DE A R T M E N T USE ONLY <br /> ASH pEPAR 2 �aS <br /> N� Application Accepted By Date Area _ Employee ID#� I Z1V <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date - WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well DeRth ft <br /> COMMENTS\lv l)y \;Q <br /> PE SC Received Check Amount Date Perm it/ <br /> Invoice# Well ID# <br /> Codes Info By_ Remitted Service Request# <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4/30/12 <br />