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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 />NUN-KEFUNDABLE PERMIT UALL (LUV) VO3-/t1V/ FOR INSPECTIONS CJCt9KY5 7 TEAR FROM DATE ISSUED <br />JOB ADDRESS 14430 DONAHUE AVE yy< �*l CITY/ZIP <br />' RIPON, 95366 <br />CROSS STREET N. RI PON RD APN { J 1lJ I PARCEL SIZE 1' 41 LAND USE APPLICATION # <br />OWNER NAME JOE LUIS PHONE 531.4747 <br />OWNER ADDRESS 14430 DONAHUE AVE CITY/STATE/ZIP RIPON, CA 95366 <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 r+ CITY/STATE/ZIP <br />LICENSE C-57 C-61 D-09 XOther C 1 0 NUMBER 662732 EXPIRATION DATE 01/31/19 <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township _ Range Section <br />NTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System <br />If different from Owner'. a er 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 Boring(s) # of borings Geotechnical # of borings <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />New Pump A 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 It <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched Steel I Plastic Stainless Steel 1 Other <br />Grout Seal Depth ft i Neat Cement (94/b bagr5-10 gal water) I Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) ' Other <br />Grout Placement Method Pumped Free Fall I Other Retardant /Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor Other <br />Concrete Pedestal Dimensions. Width It Length ft Thick in Christy Box Stove Pipe <br />PUMP XSubmersible Turbine Other HP 1 Pump Set 80 ft Standing Water Level 47 ft <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOA UNTY DINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />C RENT A A I E WITH T CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />RKERS CO P TION A S. <br />U 2 O AD OTICE REQUIRED FOR INSPECTIONS - LEASE CALL (209) 95(/, <br />3y-7697 <br />SIGNE TITLE— lw 1\17 I A- DATE / t/ �2 / r <br />Application Accepted By, <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />DEPARTMENT}USE ONLY <br />(� Date I <br />Date <br />Date <br />Date <br />Area g l q q Employee ID# +' h m( <br />11 SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth ft <br />_Z) <br />M <br />n <br />O <br />m <br />N <br />H <br />PE <br />Codes <br />SC <br />Info <br />Received Check#/ <br />By Cash <br />Amount Date <br />Remitted <br />Permit/ Invoice # Well ID# <br />Service Re uest # <br />y3V1 <br />oso <br />as�s� <br />�� <br />() <br />EHD 43-06 WELL /PUMP PERMIT <br />4/30112 <br />0 <br />