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WELL/PUMP PERMIT
<br />SAN JOAQUIN C.UL1Nt'Y ENVIRONMENTAL. HEALTH DEPARTMEAft 1868, EAST HAZELTdN AVENUE - STOCKTON CA 95205 • {209) 4684426
<br />NON-REFUNDABLE PERMIT CALL(209) 953.7697 FOR INSPECTIONS EXPIRESi YEAR FROM DATE ISSUED
<br />Joe Ar,DRE s 7272_LATNROP RD_ ...-.---.-.--- _... _.... —_—._. _. CITY:zIP ,. MANTECA 95336 _
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<br />(CRUSS STREET,vC VTTAGEAPN✓� `�/ PARCEL SIZE �_V LAND USE APPUCATiUN:tl
<br />i OWNER NAME ,. HOLFMAN & SONS PHONE ___823,i✓775
<br />OWNER ADDRESS ...,_�f -1 7_.:...•.•_1{....0 A� .�.........__....—..... .........—..__.____.. CITY/S7ATE1ziP._....-MANTEC7M1—!A_9533.6........._...
<br />CoNTRAcmR N,._&.._S,I_R_RIGATIQN. I_NC_--_. P"oNE 209.599,,.
<br />ICONTRACrok ADORES& _.��_J._31..Y.._LYJ,GIIL'1 V.1.1..]LL,1.-.......,. ..., ..._ CITYATATrjzjP...I.l).[....)./AY.....VA....
<br />ISUncoNTrtAcTUR PFro
<br />1SUIMONTRACTORADDRESS _„ .._.._.,._..,._............._._..._..... __,.... .....,. ..._..._..... CITY7STAT,12'iP.-.......... ..., • ,,,.......,, ,..,. ....
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<br />I_L_EN_s_P .. __."I D'09 XOther _........................
<br />� ._._ TION n_xT_EEXPtRX
<br />....._....._ ........-_.... ..__........
<br />GEOISRAPHICAL)N(OAMAnoN Coordinates X Y ._-., Township- Range ___ _, Section__ I;
<br />(INTkNDEo g8 xDornt>gticrPnvnte Iirlgation/Agmulturm Indusinal Water Comity Monitoring Soil Sampf ng'Cnaraclenzation 4�
<br />II1 PUDIri Water Systern
<br />_..................
<br />....... Ir 1116.. i rrurn hvmv ......... _...'" •, . _.. T'n. aYx r •1 �`—•_ .. , ...__Tnu+ia:`.t'ha+rw
<br />L.. ..., .. ,,....... ................................................. ...............,.,.
<br />Q...:...., New Well Replacement Well Well lifterabontModification Other _..
<br />tion BnraT (rs)x tasnrKre: Geotechnical
<br />Ot'l Of.Service. Well -" Oul-Of•Serwce Well Renewal Cross;-Connertion Repair
<br />p._-_..,,urnpRcpirx:e.f'i q�Rep�il_..__...._-.__.._.........,.._....._.Raise,VYell•Casrn9..._....__.....__....._._........---.......-._...__..._._.._----,
<br />i WELI. CUNsjRUCTIUN I
<br />!Drilling Method Mud Rotary Air Rotary Auger Cable tool Push Point Other_.......____._—•_.___.__—.....,____.._...............__.,,.. I!
<br />Proposed Well pr^pthit Excavation u'1 diamnter Cjen Bottom Grave) PackiG"Vei S:ze in 1jit"noter
<br />i
<br />Conductor Cas ng .-_ in diume(Pr 1 Conductor Casing Depth ...- ..-..... ... .............
<br />...._..,.it
<br />Wen Casing Diameter .._..._ in 'Thitimess/GaugeIASTM Schrd............. _... __..... .._ Steel plastic Stainless Steel Other.
<br />Grout Seal Depth .......... h Neat Cement (Aa b L.av 5 1 f q l wale?) Sand Cement_, _ ....... sack mix7 gal vaster
<br />R ntome(20%sokds) Other
<br />Grout Placement Method PumtYad Free Pall Otrier Raiardani ;Act elarator (name) ,w...
<br />.....
<br />If"9193YAL Installed B Oriller Pump Conmaclor Other
<br />Y _.
<br />.%...,Concrete Pedestal Dimensions. Width it Length it Thick In Christy Box Stove Pipe
<br />Tumine Other .-_---____ Hi __j___ Pump
<br />Water Level
<br />I HEREBY'CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN
<br />JOAQUIN ORDINANCES, STATE LAWS. AND RULES AND REGULATIONS. f 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 />y
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<br />DEPARTMENT USE ONLY
<br />Application Accepted By _ _.— Date / -3
<br />Grout Inspection By
<br />Pump Inspet:how 8*,, _ , '.% .-• <•;L� "" Date
<br />Soil Bel Ing Ing JJn By .----. Date
<br />COMMENTS __4 ll`3_. �f_Li`✓ ! �� `..—..-_._.
<br />Area / CIG Empteyee IDN / t1.5 %C j7L'(C/e5
<br />SPECIAL Well Permit
<br />WAIVER Received
<br />Constructed Well Depth
<br />r-- - - ---- �? Y.....
<br />Codes Into Ill B
<br />X 5y Received
<br />V41.7
<br />Che Amount
<br />.._—.__ Casn Remitted �—
<br />j 171 E 5-3
<br />DamrtniU invoice #
<br />Service Request # ------
<br />•
<br />Well in9r
<br />------_._._...-------.....�
<br />_._..._............. -_
<br />CHO 4:i.,x! WELL
<br />.61;12
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