Laserfiche WebLink
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 /> N <br /> JOB ADDRESS 22523 S, UNIONRD Cm/zlP MANTECA 95336 D <br /> 0 <br /> CROSS STREET W RIPON RD APN LPARCEL SIZELLAND USE APPLICATION# m <br /> e <br /> OWNER NAME BOB AGDOUMA PHONE 823.3256 •"' <br /> OWNER ADDRESS 92523 UNION RD CITYiSTATE/zIP MANTECA, CA. 95336 <br /> CONTRACTOR N& S IRRIGATION INC PHONE 209.599.3456 <br /> CONTRACTOR ADDRESS 015 W. MAIN STREET CITY/STATE72.IP RIPON, CA 95366 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C-57 -I C-61 7 D-09 XOther C10 NUMBER 662732 EXPIRATION DATE 01/31/19 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section <br /> INTENDED USE Domestic/Private I Irrigation/Agricultural i j Industrial i Water Quality Monitoring ❑Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner er y em ame <br /> Contact arra or 11none NUM06f <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br /> Monitoring Wells) #of wells . Soil Boring(s) <br /> tt of bonngs Geotechnical tt 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 /> 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 .1 Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched 7 Steel C;Plastic ❑Stainless Steel :I Other <br /> Grout Seal Depth ft Neat Cement(94 lb bag/5-10 gal water) Sand Cement sack mir./7 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 XSubmerslble._ Turbine C Other HP 1-5 Pump Set ft Standing Water Level ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQ OUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CU NT A D ACTT IT <br /> THE C LIFORNIA WCONCTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WO ERS C MPEN NLAU HO DV N6V QUIRED FOR 1 SPECTTIIO]N^S A-PLEASE CALL(209)99513-7697 <br /> SIGNED TITLE <br /> DATE <br /> N <br /> S I kill I <br /> I V I <br /> ------------- <br /> tb <br /> Alp <br /> co <br /> RTM��T <br /> F3D AR ENT USE N �/�/ <br /> Application Accepted By ' atel Area-�� Employee ID#._AA ' <br /> t Inspection B Date PECALBIIPermit <br /> Grou p y <br /> Pump Inspection By Date - WAIVER Received <br /> i <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS A A <br /> PE SC Received hec Amount Date Permit/ Invoice# WellID# <br /> Codes Info By as Remitted Service Re uest# <br /> EHD 4106 WELL/PUMP PERMIT <br /> 460/12 <br />