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WELL/PUMP PERMIT <br /> SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT i F.5£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 /> H <br /> JOB ADDRESS 8092 E.SOUTHLAND RD. `�4 cri lLP MANTECA. 95336 ^� <br /> CROSS STREET COTTAGE APN 7 0,dr�lI j t 1 PARCEL SIl LANO USE APPLcA'nON# <br /> OWNER NAME DIANE VALENTINE PHONE 239.1232 <br /> OWNER ADDRESS 8092 E.SOUTHLAND RD. CITYISTATE2tP MANTECA,CA.95336 <br /> CONTRACTOR N&S IRRIGATION, INC PHONE 209.599.3456 <br /> CONTRACTOR ADDRESS 215 W- MAIN STREET cITYIsTATil RIPON CA,95366 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C-57 C-61 D-09 XOther Ci 1 0 NUMBER 662732 EXPIRARON DATE 01/15 <br /> GEoGRAPI*CAL IN ATION: Coordinates X Y Township_ Range Section_ <br /> INnalmoUllesticlPrivale Irrigation/Agricultural Industrial Water Quality Monitoring Sal Sampling/Characterization <br /> Ubfic Water System <br /> II dlremm from OwnerW.I. em ma o ame w l Nl <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br /> MordlOring Wells) A of walls Soil Boring(s) i°r°Ot�ro' Geotechnicat <br /> Out-Of-servpo4mr-, Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pu X Pul Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Paint Other <br /> Proposed Well Depth ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter I Conductor Casing Depth ft <br /> Well Casing Diameter_in Thidmess/Gauge/ASTM Silted Steel Plastic Stainless Steel Other <br /> Grout Soal Depth ft Neat Cement(94 lb bag(5-10 gal water) Sand Cement sack mall 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 /> c e Pedestal Dimensions:Width ft Length R Thick in Christy Bos Stave Pipe <br /> ILUMP ( mersible Turbine Other HP Pump SetR Standing Water Level h <br /> 1 HEREBY C RWY 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 ACTNE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MI M 24 OU �ANNO E REQUIRED FOR ECTIONS-PLEASE CALL(209)9963-7697 <br /> SMWD TI DATE <br /> N <br /> S 4 <br /> ENDO <br /> 1ou <br /> ? <br /> IN*4l <br /> aT <br /> All <br /> �,t DEPARTMENT USE NLY I <br /> Application Acceptedey . '—`� - _ Date `D I. '� Area C'3 EmployeelQ+tl 1a�`o�a44oy <br /> Grout Inspection By ate— SPECIAL WDIIPermit <br /> Pump In Date WAIVER Received <br /> Soil Boring In By Constructed Well Depth R <br /> COMMENTS <br /> PE SC Received ee Amount Date Permit' Invoice 0 Well IDY <br /> Codes Info Remitted Service Request# <br /> C& i SR 6 28 <br /> FND 43- WELL/PUMP PEF Mn <br /> 4'30,1; <br />