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i <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />I IUIV-K"UNUALiLt YtKMI l %,ALL (LUU) UO3-/0`J/ FOR INSPECTIONS <br />LAYIKtS 7 YEAR FROM UATE ISSUED <br />JOB ADDRESS <br />17104 E. MELLO <br />CITY/ZIP <br />RIPON, 95366 <br />Pump Inspection By <br />` <br />J WAIVER Received <br />CROSSSTREET MURPHY <br />RD APN ✓ <br />PARCEL SIZEa-0-6LAND <br />USE APPLICATION# <br />OWNER NAME <br />PAUL LAGER <br />PHONE 599.6635 <br />OWNER ADDRESS <br />17104 E. MELLO LPO F?D)� 6M <br />CITY/STATE/ZIP <br />RIPON, A. 95366 <br />CONTRACTOR <br />N & S IRRIGATION, INC <br />PHONE 209.599.3456 <br />CONTRACTOR ADDRESS 215 W. MAIN STREET <br />CITY/STATE/ZIP <br />RIPON, CA. 95366 <br />SUBCONTRACTOR <br />PHONE <br />SUBCONTRACTOR ADDRESS <br />LICENSE C-57 C-61 D-09 <br />�+ <br />CITYISTATE/ZIP <br />XOlher C 1 0 NUMBER 662732 EXPIRATION DATE 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 on a ame or one Number <br />TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br />Monitoring Wells) # of wells Soil Boring(s) # of borings Geotechnical # or <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/b 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 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 />JOA C TY ORDI NCES, STATE LAWS, AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CUR NT AN . ACTIV IT <br />T E LIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WOR S COMPENSA O LA <br />M 4 R REQUIRED FO IN, P�/F�ryC�TI NS - lPLE/ASE CALL (209_) 9 3-7697 <br />SIGNED TITLE r `i ' i `rr l.- DATE / <br />Application Accepted By ` <br />Date GQ <br />Area Employee I D#,04!j+j0tiY <br />Grout Inspection By <br />Date <br />PECIAL Well Pe.it <br />Pump Inspection By <br />Date / Ze11 <br />J WAIVER Received <br />Soil Boring Inspection By <br />Date <br />Constructed Well Depth ft <br />COMMENTS <br />PE SC Received heck# Amount Date Permit/ Invoice # Well ID# <br />Codes Info <br />By s Remitted Service Re uest# <br />QI PG;7D.2stdv2 77 1 A 11 I WP0036U 3 <br />EHD 43-06 WELL /PUMP PERMIT <br />4/30/12 <br />