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Pf � <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN-MtFUNUABLE PERMIT V ZU9 953-/b9/ FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 19589 E. RIVER RDC CITY/ZIP RIPON, 95366 <br />CROSSSTREET MURPHY RD APN J PARCEL SIZE LAND USE APPLICATION# <br />OWNER NAME PETER OGELSANG PHONE 599.3402 <br />OWNER ADDRESS 19589 E. RIVER RD CITY/STATE/ZIP RIPON, CA 95366 <br />CONTRACTOR N & S IRRIGATION, INC PHONE 209.599.3456 <br />CONTRACTOR ADDRESS 215 W. MAIN STREET CITYISTATE/ZIPRIPON CA, 95366 <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br />LICENSE 1 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 />NTENDED USE X Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System <br />If different from Owner water ys em Name contaCt Name or Phone NUMber <br />TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br />Monitoring Wells) # of wells Soil Boring(s) # of borings Geotechnical # of bonngs <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 Ib 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 It Length It Thick in Christy Box Stove Pipe <br />PUMP XSubmersible Turbine Other HP Pump Set 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 />CURRENT -AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />INIU 34 OUR A V' N E ICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209,)) 995/3-776/97 p <br />SIGNED:7 TITLE " F I 6 Lw- - DATE ( (X� I <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />EP RTMENT ISE ONLY <br />ate <br />Date <br />Date—1 <br />Date <br />rn <br />H <br />D <br />X <br />41 <br />N <br />REcEIVND <br />r Z52017 <br />1/7ROFNbfE , fl <br />rufNT <br />Area Employee ID# t;�"L -/ <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth ft <br />PE SC Received Chec <br />Codes Info B ash <br />Amount Permits <br />emitted Date Service Request # Invoice# WeIIID# <br />EHD 43-06 <br />4/30/1'2 <br />WELL /PUMP PERMIT <br />