Laserfiche WebLink
-� Wit"(,7 <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 /> JOB ADDRESS 11A. MAIN ST. cITYmP MANTECA, 95337 D <br /> 0 <br /> CROSS STREET S.WOODWARD APN 0�0PARCEL SIZE LAND USE APPLICATION# m <br /> OWNER NAME KIM MARTIN PHONE 482.2099 y <br /> ,S OWNERADDR�ss ItfS. MAIN ST. CITY/STATE/ZIP _MANTECA. CA. 95337 <br /> CONTRACTOR N &S IRRIGATION, INC PHONE 209.599!3456— <br /> v CONTRACTOR ADDRESS 215W. MAIN STREET CITY/STATE/ZIP RIPON CA. 95366 <br /> �+ <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C-57 I I C-61 I D-09 XOther C10 NUMBER 662732 EXPIRATION DATE 01/31/19 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br /> INTENDED USE Domestic/Pnvate Irrigation/Agricultural "Industrial I Water Quality Monitoring i Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone um er <br /> \ TYPE OF WORK New Well Replacement Well I I Well Alteration/ModificationOther <br /> f� MonitoringWell(s) #of wells SoilBoring(s) t<ofborings Geotechnical #ofbonngs <br /> v Out-Of-Service Well i Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump X Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> I Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Well Depth ft Excavation in diameter I Open Bottom I Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched I Steel Plastic I Stainless Steel f i Other <br /> Grout Seal Depth ft Neat Cement(94 Ib bag75-10 gal water) Sand Cement sack mix17 gal water <br /> �! Bentonite(20%solids) Other <br /> Grout Placement Method I i Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width ft Length ft Thick in Christy Box Stove Pipe <br /> PUMP XSubmersible Turbine I Other HP__,5__ Pump Set__6D__ft Standing Water Level 26_It <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> �= URREN ND A VE WITH T CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> KERS OMP A1 <br /> 10 LA <br /> MU 4 H U D �I TICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> VV as I�I�t.L <br /> SIGNED TITLE DATE <br /> W Cl <br /> Ch <br /> OR 2 3 201 <br /> ON, <br /> MENTAL HEALTH <br /> wRMIT/S CES <br /> a, a , <br /> �-�— CIO c � E/ A(7- <br /> 2017 <br /> LLJEP RTMENT SE ONLY <br /> C1.) <br /> C OEPgp.kS• <br /> ra7�p. ( 1 implication Accepted By Date Area Employee ID# �P <br /> Grout Inspection By Date SPECIAL Well Permit <br /> N Pump Inspection By Date _ WAIVER Received <br /> Soil Boring Insp do By Datf Coonnstructe Well Depth ft <br /> COM ENTS G �/ Ow c✓ ! >w 6fC'Cc� 7hrb s+t4a s <br /> PE SC Received Che It Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By ash Remitted Service Re uest# <br /> % da.z� D U� 3 2� 1200�701QZ <br /> END 43-06 WELL/PUMP PERMIT <br /> 4/30/12 <br />