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t WELL/PUMP PERMIT A43CEIVED <br /> SAN JOADUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CABSNON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROJOB ADDRESS CITYIZIP/- MANTECA 95336Y 208 <br /> CROSSSTREET E SOUTH AND RD APN 0 �� PARCELSIZEO l7�LANDUSE APPLICATION# <br /> ENV! �lq�ICNT;�L, <br /> OWNER NAME MIKE C)IIII IC'I PHONE 209232-0962 L' FIA RT HIEN <br /> OWNER ADDRESS 15661 S AUSTIN RD CITY/STATE/ZIP MANTFCA, CA 95336 <br /> CONTRACTOR N&S IRRIGATION INC PHONE 209.599.3456 <br /> CONTRACTOR ADDRESS 215 W MAIN STR F ET CITYISTATE/ZIP RIPON, CA, 95366 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATEIZIP <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 Pey C�j <br /> If different from Owner: Water System Name Contact NaFW—or-37one NUMIDef c <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification i Other 'IED <br /> Monitoring`A:ell(s) #of wells Soil Soring(s) #of borings Geotechnical #of borings <br /> Out-Of-Service Well i Out-Of-Service Well Renewal Cross-Connection Repair MA4TMENT Z��B <br /> New Pum X Pum Replacement Pum Repair Raise Well Casingn <br /> WELL CONSTRUCTION <br /> OAQUI <br /> Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other "AN.— OUNTY <br /> Proposed Well Depth ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size TA <br /> H atfi�i <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad i Steel i Plastic i i Stainless Steel i Other <br /> Grout Seal Depth ft Neat Cement(94/b bag/5-10 gal water) i 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 It Length ft Thick in Christy Box Stove Pipe <br /> PUMP XSubmersible Turbine 1 Other HP__I__ Pump Set 100 ft Standing Water Level-4_7 It <br /> I HEREBY CERTIFY THAT 1 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 /> CU ND ACTIV WITH THE CAL FORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> RKERS OMPENS TIPN LAWS <br /> MIN MUM 4 OUR NYCE T CE REQUIRED FOR <br /> 4 I.1N/S�P�E�yC7TIIONSSj-PLEASE CALL(209)953-7697 <br /> SIGNED <br /> TITLE K 1TT7 11 6 C-r C—. DATE <br /> N <br /> E <br /> S <br /> EP RTMENT U E PNLY <br /> Application Accepted By Date Area 'J C Employee ID#�I't t�V <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By r1,4iA,A r Date 9 54 WAIVER Received <br /> Soil Boring Inspection By uL NSQ <br /> Dat Constructed Well Depth ft <br /> COMMENTS I� u 4 CCC S-) fCc,LI Dlil.r j— D/(t—"g, . FC.Ll D Ix' if <br /> PE SC Received ,theckV Amount Date PermlU Invoice# Well ID# <br /> Codes Info B Remitted Service Request# <br /> WP -- <br /> EH D 43-06 WELL/PUMP PERMIT <br /> 4/30/12 <br />