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PI <br />RE., L-- -- <br />NOV- <br />-V ✓ <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 /, UALL (ZUV) 1153-76117 FOR INSPECTIONS tAPIKt5 7 YEAR FROM DATE ISSUED <br />t- pp � <br />JOB ADDRESS 21508 WY 99 FRONTAGE p If—t� CfTY/zIP RIPON 95366 <br />CROSSSTREET AUSTIN RD APN ZZa O� (]v PARCEL SIZE LAND USE APPLICATION <br />OWNER NAME FRANK BORGES PHONE 484.0856 <br />OWNER ADDRESS 1518 THUNDERBIRD DR CITY/STATE/ZIP MODESTO,CA 95356-9674 <br />CONTRACTOR N & S IRRIGATION, INC PHONE 209.599.3456 <br />CONTRACTOR ADDRESS 215 W. MAIN STREET CITYISTATE/ZIP RIPON. CA, 95366 <br />ADDRESS <br />CITYISTATE/ZIP <br />PHONE <br />LICENSE C-57 C-61 D-09 XOther C10 NUMBER 662732 EXPIRATION DATE 01/31/19 <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br />INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System <br />If different from Owner: Water System Name on a Nam or one Number <br />TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br />MonitoringWell(s) #of wells SoilBoring(s) #ofbonngs Geotechnical #ofbodngs <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <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 bag/5-10 gat water) Sand Cement sack mixn gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method Pumped i Free Fall Other Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor Other <br />Concrete Pedestal Dimensions: Width ft Length ft Thick in Christy Box Stove Pipe <br />LU MEP XSubmersible Turbine Other HP 1 Pump Set 0 ft Standing Water Level 5 ft <br />I Y CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />OAQUIN OUN ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />RRENT ND AC IVE ITH HE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />W ERS CO E SATIO L S. <br />H U NOTICE REQUIRED FORIINSSPP JF7////CTTtIONN_Stn/- PLEASE CALL (209) 953-7 97 <br />SIGN TITLE ' T�r-71 W4/ DATE-�' (� <br />NOV 0 7 2017 <br />SAN,}OAQUIN GOU <br />EHVIRONMEWAI- <br />HEALTH DEPAR <br />TMEN <br />DFT ARTMENT U E NLY <br />Application Accepted By Date <br />�y Grout Inspection By Date <br />Pump Inspection By ` Date <br />Soil Boring Inspection By Date <br />COMMENTS <br />Area Employee ID# AH►j0 <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth It <br />PE SC Received <br />Codes Info By <br />Check# Amount Date Permit/ Invoice # Well ID# <br />s Rem-itted Service Re uest# <br />�i> <br />/ ,D / <br />% <br />EHD 43-06 <br />4/30/12 <br />WELL /PUMP PERMIT <br />Z <br />