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Q <br />WELL/PUMP PERMIT <br />SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468.3420 <br />PERMIT <br />EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 17541 E. EUGENIA' V" <br />CITYIZIP RIPON 95366 <br />CROSS STREET WAGNER RD APN <br />V %� <br />ARCEL SIZEr� AND USE APPLICATION # <br />OWNER NAME DOMINIC IPPOLITO kLihD.Vl <br />1� <br />L PHONE 815.6341 <br />OWNER ADDRESS 17541 E. EUGENIA <br />CITY/STATE/ZIP RIPON, CA 95366 <br />CONTRACTOR N & S IRRIGATION, INC <br />PHONE 209.599.3456 <br />CONTRACTOR ADDRESS 215 W. MAIN STREET <br />CITY/STATE/ZIP RIPON, CA, 95366 <br />SUBCONTRACTOR <br />PHONE <br />SUBCONTRACTOR ADDRESS <br />C-57 C-61 D-09 <br />CITY/STATEIZIP <br />XOther C 1 0 NUMBER 662732 EXPIRATION DATE 01/31/19 <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township _ Range Section <br />INTENDED USE X Domestic/Private Irrigation/Agrcultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System <br />If different from Owner: Water System Name one ame 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 eons Geotechnical # of borings <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross-Cnnnection 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 bag15-10 gal water) Sand Cement sack mixt/ 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 ft Thick in Christy Box Stove Pipe <br />PUMP XSubmersible Turbine Other HP ___3_ Pump Set 120 ft Standing Water Level 45_ ft <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAPUIN COUNTY O INANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />REN ND ACT 11 WITH HE LIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />ORKERS OMPEN A O LA S. <br />I UM U A V ICE REQUIRED FO�R/► INSPECTIONS <br />/- PLEASE CALL (2091953-7697 <br />SIGNED TITLE IV LNI Jr✓ DATE <br />10, <br />ppYMEN� <br />RECEfV ED Application Accepted By' <br />_ Grout Inspection By <br />2011 <br />Pump Inspection By <br />9 ry <br />JOAnUtµ GOUh' Soil Boring Inspection By <br />SAS <br />HOEPAP,V COMMENTS <br />4 <br />P <br />T <br />AWANNME <br />Ir ■�00■■■■ ��ii.l��N �■■ <br />i%J�I�■■■■■■■■■■■ ■■ice■■■■■■■ \� <br />I■■■■■■■■■■■■■■■■■■■■■■■■■ <br />PE SC Received C Amount PermiU <br />Codes Info B Cash Fiernitted Date Service Request # Invoice # Well ID# <br />025 Z vJ <br />EHD 43-06 <br />4/30/12 <br />WELL /PUMP PERMIT <br />