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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 /> fA <br /> JOB ADDRESS 10633 SOUTHLAND RD CITY/ZIP MANTECA, 95336 m <br /> D <br /> 0 <br /> CROSS STREET AUSTIN RD _AP PARCEL SI2 LAND USE APPLICATION# m <br /> OWNER NAME ROBERT CASAZZA PHONE 209.665.5432 N <br /> OWNER ADDRESS 10633 SOUTHLAND 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 DOmestlC/Pnv to Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water System Name Contact Nam or one um er <br /> �\ TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells Soil Boring(s) #of bongs Geotechnical #of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pum X Pum Replacement Pump Repair Raise Well Casing <br /> '*lr ems, �• �• LL CONSTRUCTION <br /> uYe�� fling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Well Depth ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> iaaSvr •� U 'C10Conductor Casing in diameter / Conductor Casing Depth ft <br /> Cyltell Casing Diameter_in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br /> Grout Seal Depth It Neat Cement(94/b bag/5-10 gal water) Sand Cement sack mix/7 gal water <br /> CL) <br /> Bentonite(20%solids) Other <br /> 7 �- ('trout Placement Method Pumped Free Fall Other Retardant/Accelerator(name) <br /> L'CS L_ <br /> � QVWESTA�L Installed By Driller Pump Contractor Other <br /> .+eam T (, Concrete Pedestal Dimensions:Width ft Length ft Thick in Christy Box Stove Pipe <br /> C`J XSubmersible Turbine Other HP--j _ Pump Set _ft Standing Water Level___4D _ft <br /> ,. 1= CERTIFY TH T I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> .C7 AQUIN UNTY O ANCES, STAT LAWS, AND RULE ND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> �1JtRENT ND ACTT E IT H T E C I I RNIA CONT ORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> �) RKERS COMPEN ATI LAW . <br /> UM 4 R DTAN E REQUIRED FOR IIN/SJ.P,E/CTTIIOyN_SS--PLEASE CALL(209) 5 76 <br /> SIGNE TITLE r Y'\�'f 1 V Cs DATE � f <br /> N <br /> E <br /> S <br /> RECEI 4 y <br /> xY _ <br /> JUL Z 8 <br /> EN1iIRONMf NT <br /> ftfffi <br /> PERMIT/SER o <br /> o � <br /> f <br /> DE P A R T M E N T S E �N L Y Area , Employee ID# <br /> Application Accepted By Date <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date _ WAIVER Received <br /> Soil Boring InjWection By Date Constructed Well Depth ft 1 �� <br /> COMMENTS �t �N/ �' M <br /> 2 ca k- q <br /> PE SC Received Check Amount t Permit/ I,��� <br /> Date <br /> Codes Info By Cash Remitted Service Re uest# Invoice# Well ID# <br /> So 254 47 7n' 2� 11 q G'03 o <br /> EH D 43-06 WELL/PUMP PERMIT <br /> 4/30/12 <br />