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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 /> i y <br /> JOB ADDRESS 30636 E. CARTER RD. CITY/ZIP FARMINGTON. 95230 I o <br /> CROSS STREET S. HENRY RD. APN-." ?� 1���3t?c•t� PARCEL SIZE��_LANE)USE APPLICATION# m <br /> rn <br /> OWNER NAME _ JENKINS POULTRY PHONE 886.1000 y <br /> OWNER ADDRESS 309636 E. CARTER RD. CITY/STATE✓ZIP FARMINGTON, CA. 95230 <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-01/31/17 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section <br /> Domestic/Pnvate Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Charactenzation <br /> Public Water System <br /> r7� <br /> dtllennt Iron Owner. Wwer syslernNa— Contact Na or ane NUInWr <br /> TYPE OF WORK New Well Replacement Well Well AReration/Modification Other <br /> Monitoring Wells) #of Wells Soil Borings) SO IwnW, Geotechnical Aofeonngs <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 Gravel Pack/Gravel Size_ in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth fl <br /> Well Casing Diameter__ in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other. <br /> Grout Seal Depth_ ft Neat Cement(94 Ib bag/5-f0 gal wafer) Sand Cement _sack miNR 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�7—,n in Christy Box Stove Pipe <br /> !PUMP XSubmerslDle Turbine Other HPSet Pump tt Standing Water Level 142 ft <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 /> WORKERS COMPENSATION LAWS. , <br /> MINIMPM 24 HOUR ADVANCE NOTICE REQUIRED FOR WPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED i• y- TITLE % DATE <br /> N <br /> E <br /> S L I P4 v N� <br /> i <br /> Ra��ya <br /> DFaMFMr�'hY <br /> I <br /> 0 � <br /> o DEPARTMENT SE ONLY <br /> Application Accepted By ti/"l_ Date �Z Area Employee ID#��-cow- <br /> Grout Inspection By I�te -SPECIAL Well Permit <br /> Pump Inspection By / Date ._ WAIVER Received <br /> Soil Boring Ins /tion By _ Date Constructed Well Depth ft <br /> COMMENTS� <br /> PE I SC Received r eek# Amount Date Permit/ Invoice# Well IDN <br /> Codes Info B ash Remitted Service Re uest# <br /> 0531 0 J "?.2-0 s3 J s /�`1'*P42Z <br /> EHD X3-04 <br /> 430n2 WELL rt'UMP PERMIT <br />