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WELL/PUMP PERMIT RECE1VED� <br />SAN JOAOUIN 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 ISS 2018 <br />JOB ADDRESS q J� CITY/ZIP LATHROP 95330 *. �.m v <br />� --R _ e <br />CROSSSTREET MCKINI FY AVE APN ' (/ " v PARCELSIZE LAND USE APPLICATION # NTA L •i�'A �T�• <br />�-` <br />OWNER NAME JOE ROSA PHONE 209.810.0895 4TIN1ENT <br />OWNER ADDRESS 3155 W YOS MIT AV .1 Po oy 4%� CITY/STATE/ZIP LATHROP, GA 95330 <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 />NTENDED USE Domestic/Private Irrigation/Agricultural Industrial i Water Quality Monitoring i Soil Sampling/Characterization <br />Public Water System <br />If different from Owner Water SysteM ame Confact Name or Phone Nurn r <br />TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br />Monitoring Wells) # of wells Soil Boring(s) # of borings Geotechnical # of borings <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />New Pump X Pump Replacement Pump Repair Raise Well Casing <br />PA�M��E <br />PQU\N <br />5���\FzONF <br />jkA pE <br />Drilling 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 />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched i Steel i Plastic i Stainless Steel iI Other <br />Grout Seal Depth ft Neat Cement (94 Ib bag15-10 gal wafer) Sand Cement sack mixR 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 ft Length ft Thick in Christy Box Stove Pipe <br />PUMP XSubmersible. Turbine Other HP __J_ Pump Set_____2B__ ft Standing Water Level --- jj_ ft <br />I HER Y CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JO UI COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />RRENT 4AC WITH HE LIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />RKERS CON LA S. <br />H U A VAN ICE REQUIRED FOR <br />^ INSPECTIONS -PLEASE CALL (209) 953--7(697 <br />SIGNED - k TITLE Wl 1 �'A DATE � % <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />E Pk RTMENT USE Y <br />Date <br />Date <br />Date <br />Date <br />Area �!I/ Employee ID#?J& r —Y <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth ft <br />PE SC Received <br />Codes Info B <br />(Checkp <br />Amount Date Permit/Invoice # Well ID# <br />Remitted Service Request # <br />1341 -n <br />z�,36q <br />5 I <br />EHD 43-06 WELL /PUMP PERMIT <br />4/30/12 <br />