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WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE P T <br /> MIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 5474 NILERS Ate, cl.r,,/zIP MANTECA, 95337 <br /> J wL D <br /> CROSS STREET S UNION RD APN TOO"- C)2 L PARCEL SIZEy�'� LAND USE APPLICATION# O <br /> m <br /> OWNER NAME ARNOLD ROTHLIN JR PHONE 209.823-9961 w <br /> OWNER ADDRESS 5474 NILE RD CITY/STATE/ZIP MANTECA, CA 95337 <br /> CONTRACTOR N &S IRRIGATION, INC PHONE 209.5.3456- <br /> CONTRACTOR ADDRESS 215W. MAIN STREET CITY/STATE/ZIP RIPON CA. 95366 <br /> SUBCONTRACTOR <br /> PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE 'I C-57 i I C-61 D-09 XOther C10 NUMBER 662732 EXPIRATION DATE 01/15 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section ` <br /> INTENDED USE _!DomestK/Private Imgation/Agricultural ! Industrial I Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System , <br /> If different from Owner: Water System Nam Contact Nam or Phone Number <br /> TYPE OF WORK New Well Replacement Well II Well Alteration/Modification l I Other <br /> Monitoring 9O Wells #of wells Soil Bodn s #of bonngs !Geotechnical #of borings <br /> Out Of-Service Well Out-Of-Service Well Ren wann [RPy <br /> New Pum X Pum Re lacemenI Pum Re r s ell sin , fi <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary Auger Cable T I U h omt I <br /> Proposed Well Depth ft Excavation in diamet f'-,,jper}�pt rp G g►�t� to diameter <br /> Conductor Casing in diameter / Conductor <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad r` R_:}5fB®�/f R1>lelM 1� sI <br /> Grout Seal Depth ft Neat Cement(94/b ba <br /> and ga wafers t'�f�TS[1a�nlldJ lCtee ent C•T sack mi-xfl gal water <br /> Bentonite(20%solids) Other hV -A�flronmpp-2t ��I I� (V-S`101r1 <br /> Grout Placement Method I i Pumped i Free Fall i Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By L Driller i'Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width ft Length ft Thick in Christy Box I Stove Pipe <br /> PUMP XSubmersiblei Turbine 1 Other. HP___1_5__5 Pump Set 40 ft Standing Water Level <br /> I HEREBY CERTIFY THAT I 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 /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORK OMPE ATION LA S. <br /> M U H�U D�OTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 EC <br /> SIGNED TITLEI V�Lk f'�- -4.zy DATE �, � �� <br /> N <br /> S E . JUL 1 5 2616 <br /> 7N�NVIRONMENTAL HEALT <br /> I'ERMITrSERWCES <br /> RFCFryNT <br /> Ep <br /> UC 18 2016 <br /> Rohm, "Oy <br /> H E DR NT <br /> a I I I I j 4 1 <br /> yt DEPARTMENT USE ONLY <br /> Application Accepted By Area V 5 t� Employee ID# <br /> Grout Inspection By Date LI SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth It <br /> COMMENTS <br /> PE SC Received (ChecMV Amount Date Pertnit/ Invoice# WeIIID# <br /> Codes Info B Remitted Service Re uest# <br /> 7-%Y.-It, S C'7 51.Hf, <br /> EHU 43-06 WELL/PUMP PERMIT <br /> 4/30/12 <br />