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12 <br />PAYMEN o <br />RECEIVE <br />9J <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN-KEFUNDABLE PERMIT L;ALL (LU`J) U5J-/b`J/ FOR INSPECTIONS tAl'IKtb 'I YEAR FROM UATE ISSUED <br />JOB ADDRESS 16569 YfOSEMITTIiT7T7tCITY/ZIP RIPON, 95366 <br />CROSSSTREET MURPHY RD APN �oe ARCEL SIZE AND USE APPLICATION# <br />OWNER NAME GOLDEN GATE NUT COMPANY PHONE 209.599.7131 <br />OWNER ADDRESS 23073 S. FREDERICK 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 CITY/STATE/ZIP <br />LICENSE C-57 C-61 D-09 XOther C10 NUMBER 662732 EXPIRATIONDATE 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: Water System Name contaCt Nam or FhOne NUMDer <br />TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br />Monitoring Well(s) # of wells Soil Boring(s) # of borings Geotechnical It of bonngs <br />Out -Of -Service Weil Out -Of -Service Well Renewal Cross -Connection Repair <br />New t-ump n rump me Iacement rump me au mise vvee Lasing <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 ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br />Grout Seal Depth ft Neat Cement (94 lb bagl5-10 gal water) Sand Cement sack mixn 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 It Thick in Christy Box Stove Pipe <br />PUMP XSubmersible Turbine Other HPJ_ 1 Pump Set 60 ft Standing Water Level�— 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 />QVRRENT AND XTIVE W)TH T,)1E CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />HQUfi� AQV N NOTICE REQUIRED FOR <br />INSPECTIONS <br />�-- PLEASE CALL (209) 953-7697 <br />�� \�/1 TITLE II" VI \ 1 V Yt 9 LJ DATE <br />�14rjV'U'7'L'j'111 11111 11111111 i 11111 ill 1 <br />so JOAclulh - <br />' " 1111111111111111111111111 1 <br />lN1ROhM, E� RTMENT U E 0 NLY <br />Application Accepted By Date <br />Grout Inspection By Date <br />Pump Inspection By \LADate <br />Soil Boring Inspection By Date <br />COMMENTS <br />to <br />D <br />°z <br />N <br />N <br />Area Employee ID#/!� <br />SPECIAL Well Permit <br />J WAIVER Received <br />Constructed Well Depth ft <br />PE Sc Received Check Amount Date Permit/ Invoice # Well ID# <br />Codes Info By ash Remitted Service Re uest# <br />� G ' <br />EHD 43-06 <br />4/30/12 <br />WELL /PUMP PERMIT <br />H�acry <br />