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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 />NON-REFUNDABLE PERMIT <br />953-7697 FOR INSPECTION5 tAF'IKtJ T T t_AK I-KOM UA I t IJJUtU <br />JOB ADDRESS <br />CROSSSTREE7 <br />19161 E. RIVER RD <br />CITY/ZIP RIPON. 95366 <br />'L <br />PARCEL SIZE �5 LAND USE APPLICATION <br />CARROLTON RD APN <br />OWNER NAME <br />OWNER ADDRESS <br />ROWAN REALTY C�¢�{ �'((�'L <br />, ,,,7J PHONE 571.3710 X 11 <br />�' Lr'1'S 9P 6,'/STATEZP MODESTO CA 95356 <br />313 MOTOR CITY CT #A l%3 U <br />CONTRACTOR <br />N & S IRRIGATION, INC <br />PHONE 209.599.3456 <br />CONTRACTOR ADDRESS 215 W MAIN STREET <br />cITYBTATE/7jP RIPON J_CA. 95366 <br />(SUBCONTRACTOR <br />PHONE <br />ADDRESS <br />LICENSE C-57 C-61 0-09 XOther <br />CITY/STATEOP <br />NUMBER 662732 EXPIRATION <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 Ownerer em Name UontaCt Name or Phone Number <br />TYPE OF WORK New Well Replacement Well fl Well Alteration/Moorticatlon L. Utner <br />Monitoring Wells) # of wells a Soil Boring(s) # of borings Geotechnical *of boenge <br />Out -Of -Service Well ❑ Out-O,Service Well Renewal Cross-Cennecticn Repair <br />Naw Pumn X Punto Reolacement I I Pump Repair Raise Well Casing <br />Drilling Method Mud Rotary Air Rotary Auger Cable Tool I Push Point Other <br />Proposed Well Depth ft Excavation in diameter 1 Open Bottom i Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Schad I Steel Plastic . i Stainless Steel Other <br />Grout Seal Depth ft Neat Cement (94 lb 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 ft Length ft Thick in Christy Box ! Stove Pipe <br />PUMP XSubmersible. Turbine Other HP 1 .5 Pump Set�Q_ ft Standing Water Level <br />I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JO&QULN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />RE ND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />NOTICE REQUIRED FO NSPECTIONS - LEASE CALL (209) 953-7779Q- <br />TTE T ) �J DATE l <br />G T <br />c„ 'd xi <br />ai � 2011 <br />SAN JOAQUen�.nF olA <br />t- 6-fH A DEFAtt t IYc� <br />r DE ARTMENT USE N L Y <br />Application Accepted By ' Date (� Z 7 r Area Employee ID#�C�i1� <br />Grout Inspection By Date PECIAL W011 Permit <br />Pump Inspection By Date ' I V WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS__ <br />PE <br />Codes <br />SC Received eC <br />Info B sh <br />Amount Date <br />Remitted <br />Permitl Invoice # Well ID# <br />Servifcle R uesstt # <br />EmD 43-06 <br />4;30112 <br />