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P✓ , <br /> + 'r 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 578'8 rIG RD. CITYIZIP MANTECA, 95337 m <br /> D <br /> UNION RD. � 5 (� ,l <br /> CROSS STREET APN �✓J v I PARCEL SIZE V' LAND USE APPLICATION# m <br /> OWNER NAME BBO/BBRRAIY�LMUS �Z�cterI4 A,C1yU')e- VA TYJAU5 ) T yP/H�ONE 1 L <br /> 470-1093 <br /> MCI Q 1/ <br /> OWNER ADDRESS 1 �/ 1,J(,1 X U CITY/STATE/ZIP / GI A i I �c( (5 5 J <br /> I <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 C 1 O NUMBER 662732 ExPIRATION DATE 01/31/19 <br /> /19 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br /> INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water System Name 0.a am 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 bodngs Geotechnical #of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Crass-Connection Repair <br /> New Pump X Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <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 Steel Plastic Stainless Steel Other <br /> Grout Seal Depth ft Neat Cement(94 It,bag/5-10 gal water) Sand Cement sack mix17 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 Submersible Turbine Other HPumpSetft StandingWater Level It <br /> I H EBY CERTI Y TH I AVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOA IN COUN OR NA CES, S ATE AWS, AND R AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURR T AND ACTIV WI H THE ALI RNIA CO ACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKER CO ENS TIO L S. <br /> M 2 AD N CE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)9 -7697 f <br /> SIGNED TITLE �T` <br /> -,JAC <br /> `v v"—' DATE <br /> N <br /> VV E <br /> S <br /> REA <br /> SE <br /> E� r <br /> pE <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date ' Area Employee ID# '� him G O <br /> Grout Inspection By Date� I SPECIAL W011 Permit <br /> Inspection By d Dat <br /> Pump e WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft 10 Cel .`vT <br /> COMMENTS c A <br /> PE SC Received "Check Amount Date PermlU Invoice# Well ID# ��P o <br /> Codes Info B Remitted Service Request# AAA 20„ <br /> �SWII S v #-,,2 � 9 11�/ SOC' G F VRQIJ/N� <br /> O OU <br /> TN p�PMR��N rY <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4/30/12 <br />