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P � s <br /> ` WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PEWIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> y <br /> JOB ADDRESS 9699 SOUTHLAND RD. CITY/ZIP MANTECA, 95337 m <br /> 0 <br /> CROSS STREET AUSTIN RD APN 2o$bq02 PARCELSIZE Z"L LAND USE APPLICATION# m <br /> H <br /> OWNER NAME GUY UCHONNET PHONE 679-0856 <br /> OWNER ADDRESS 9699 SOUTHLAND RD. CITY/STATE/ZIP MANTECA, CA. 95337 <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 Nam on a ame or one um er <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br /> MonitoringWell(s) #of wells SoilBoring(s) #orborings Geotechnical #ofbonngs <br /> Gut-Of-Service Well Out-Oi-Service Weil Renewal Cross-Connection Repair <br /> New Pump X Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION A <br /> Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other 44 <br /> Proposed Well Depth ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter fts; <br /> Conductor Casing in diameter / Conductor Casing Depth ft `,r <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br /> Grout Seal Depth ft Neat Cement(94/b bag15-10 gal water) Sand Cement sack mix/7 gal water J14*t! <br /> Bentonite(20%solids) Other <br /> S <br /> Grout Placement Method Pumped Free Fall Other Retardant/Accelerator(name) pn`��igQ 2018 <br /> PEDESTAL Installed By Driller Pump Contractor Other r/y )O M COUH <br /> Concrete Pedestal Dimensions:Width ft Length ft Thick in Christy Box Stove Pipe ORNT"�c <br /> PUMP Submersible Turbine Other HP 1 Pump Set�Q_ft Standing Water Level_45_ft TM�NT <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOA COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> REN ND AC E WI H HE CALIFORNIA.CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> ORKERS OMP S TION A <br /> IMU O V NOTICE REQUIRED FO�R�INSPECTIONS-PLEASE CALL(209)953--76697 <br /> SIGNED / TITLE I"V( l'fir-\C��T C� DATE rJ�_l <br /> N <br /> E <br /> S <br /> RECULM <br /> JAN <br /> ENVIRONME <br /> PERMIT/ <br /> =RTMENT USE LY rr�� 4�.��}�.��/��r�� <br /> Application Accepted By Date Area 0[�3 f Employee ID#i-:w-F ff5 <br /> Grout Inspection By Date SPECIAL WBII Permit <br /> Pump Inspection By �� VIW+\ Date r WAIVER Received <br /> Soil Boring Inspection By Date A Constructed Well Depth ft <br /> COMMENTS S\1� � <br /> PE SC Received he Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B ash Remitted Service Request# <br /> 8 14037774 <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4/30/12 <br />