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-r-V.74 �Utn -�-11l &?!�vr-- <br /> 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 /> Ln <br /> Jou ADDRESS MAIN ST. cITY1zIP MANTECA, 95337 y <br /> CROSS STREET S.WOODWARD APN7 PARCELSIZELAND USE APPLICATION JF m <br /> u� <br /> OWNER NAME• KIM MARTIN PHONE 482.2099 <br /> OWNER AimIR ft; S MAIN ST CITYISTATEizIP MANTECA. CA. 95337 <br /> CONTRACTOR N &S IRRIGATION, INC PHONE 209.599.3456 <br /> CONTRACTOR ADDRESS 215 W. MAIN STREET CLTYISTATEIZLP RIPON, CA. 95366 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CGTYISTATE1ZtP <br /> LICENSE C-57 C-61 D-09 XOther C10 NUMBER 662732 EXPIRATION DATE 01f31119 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br /> INTENDED USE XDomeslirlPrivate !rrgationlAgricultural Industrial Water Quality Monitoring Soil SamplinglCharacterzation <br /> Public Water System <br /> If different from Owner: aer ys em ame ora ame ar ane um r <br /> TYPE OF WORK New Well Replacement Well Well AlterationfMociification Other <br /> Monitoring Well(s) #of wells Sail Boring(s) #of donngs i Geotechnical #orherings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> NewPurnp X Pump Replacement Pump Repair Raise Well Casing <br /> WELL CQNSTA.UCT'ION <br /> Drilling Method Mud Rotary Air Rotary Auger I Cable Took I i Push Point Other <br /> Proposed Well Depth ft Excavation in diameter Open Bottom -.Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter 1 Conductor Casing Depth ft <br /> Well Casing Diameter_in ThicknesstGaugelASTM SchedSteel i Plastic Stainless Steel Other <br /> Grout Seal Depth ft I I Neat Cement(941b bag/Si0 gai water) Sand Cement Sack mrxR gal water <br /> Bentonite(20%solids) 1-Other <br /> Grout Placement Method Pumped Free Fall 1 Other Retardant 1 Accelerator(name) <br /> PEDESTAL Installed By I Driller Pump Contractor Other <br /> Concrete Pedestal -Dimensions:Width it Length ftThick in Christy Box Stove Pipe <br /> PUMP XSubmersible, Turbine Other HP__5_ Pump Set__6_a_ft Standing Water Level_26 ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JDAIDbl COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> URRENNO A VE WITH T CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> KERS OMP ATIO LA <br /> MU 4 H U D OTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE DATE <br /> 419 1 (Al <br /> rt ElVED <br /> OR 2 3 2018 <br /> 4NIMENTAL HEALTH <br /> ° RMIT/SERVICER <br /> ' NAY <br /> i RFCEIV�� <br /> MMR 2 2017 <br /> yPOh tN ti <br /> EPLMENTSE ONLY * <br /> �Ilryy�£pN�ti." <br /> r` <br /> Application Accepted By Date ` Area Employee ID# p <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date - WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check Amount Permit/ <br /> Codes Info B ash Remitted Date Service Request# Invoice# Well ID# <br /> �✓� .Z��zr� O Ub 3 Z� �d ����P2 <br /> EH 0 43-D6 wELL(PUMP PERMIT <br /> 4MI12 <br />