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y/ <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN-KEFUNUABLE F'EKMI I UALL (LU`U) `W"-/OtlI FUK IN5NG tIIUN5 <br />tAYIKtA T TEAK I -RUM DATE ISSUEU <br />JOB ADDRESS 20137 E. MELLO, rd <br />_� clTv/�ZjIP <br />RIPON 95366 <br />CARROLTON RD. <br />``11[ <br />I� O �O <br />CROSS STREET <br />APN�'IS PARCEL SIZE •'L <br />LAND USE APPLICATION# <br />OWNER NAME KENNETHKANG <br />A J,A ���I-p),A II <br />PHONE 209.599.2238 <br />OWNER ADDRESS 20137 E. MELLO RD. <br />CITYISTATE/ZIP <br />RIPON, CA. 95366 <br />CONTRACTOR N & S IRRIGATION, <br />INC <br />PHONE 209.599.3456 <br />CONTRACTOR ADDRESS 215 W. MAIN STREET <br />CITY/STATE/ZIP <br />RIPON CA, 95366 <br />SUBCONTRACTOR <br />PHONE <br />ADDRESS <br />C-57 C-61 D-09 <br />CITY/STATE/ZIP <br />XOther C 1 0 NUMBER 662732 EXPIRATION DATE 01/31/19 <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section <br />INTENDED USE Domestic/Private Irrigation/Agricultural I Industrial Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System <br />If different from Owner Water System Name contact Name or Phone Number <br />TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br />Monitoring Well(s) # of wells Soil Bodng(s) # of borings Geotechnical <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br /># of borings <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 It Neat Cement (94 Ib bag/5-10 gal water) Sand Cement sack mix/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 it Length It Thick in Christy Box Stove Pipe <br />PUMP XSubmersible Turbine Other HP 1 Pump Set 95 ft Standing Water Level 60 ft <br />I H BY C TIFY THF I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOA UIN COU TY O INANCES, ST LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CUR NT AN ACTT E WITH T AL FORNIA CONTRA S STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKE CO PEN TION LAW . <br />I URANC N T E REQUIRED FOR <br />�INSPECTIONS <br />�_yPjl(JE'ASE CALL (209L953-76 7 <br />SIGNED TITLE f� Y I "' ` `--� y _ DATE U <br />y <br />D <br />M <br />N <br />N <br />DEPARTMENT USE ONLY !� <br />Application Accepted By Date 9 V ( Area Employee ID#LS i4 } <br />Grout Inspection By Date n ` SPECIAL Well Permit <br />Pump Inspection By Date '� V (� WAIVER Received <br />Soil Boring InNection By Date Construed Well Depth ft <br />COMMENTS /[r ii�S O z !/ ' �i r�le4( wi� �Gle�' ! jZ (! i/l4J P �v�' �) '✓i+r�/1r$ <br />1 11 1 1" I f =:c' ' 1 1 Date I I Invoice # I well ID# 134N <br />103Y/1 sU 1 C(5 IP*r 579 1 `1' 7 I I /Y" -AT <br />EHD 43-06 <br />4/30/12 <br />WELL /PUMP PERMIT <br />3 <br />SFp ��VFO <br />I,' Q <br />H�FPgRT q �rY <br />MENT <br />