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REci <br />Size <br />NVIROWtIv <br />PERMIT/SE <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 11403 W RIPON RD CITY/ZIP RIPON 95366 <br />CROSSSTREET S. FREDERICK AVE. APN 4Zo . <br />� PARCELSIZE O LAND USE APPLICATION# <br />OWNER NAME JOHN VRIELING fjj,N (je5-f, /7 f4 A;? PHONE 209.614.1235 <br />OWNER ADDRESS 11403 W. RIPON RD/ N &k� jj CITYISTATE/ZIP RIPON, CA 95366 <br />CONTRACTOR N & S IRRIGATION, INC PHONE 209.599.3456 <br />CONTRACTOR ADDRESS 21.51 W MAIN STREET CITY/STATE/ZIP RIPON. CA, 95366 <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS CITY/STATEIZIP <br />LICENSE C-57 C-61 D-09 XOther C10 NUMBER 662732 EXPIRATIONDATE 01/31/19 <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section <br />NTENDED USE X Domestic/Private 1 Irrigation/Agricultural i Industrial Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System <br />If different from Owner: Water System Nam GontaCt Name or Phone um er <br />TYPEOF WORK New Well Replacement Well i i Well Alteration/Modification i.. Other <br />Monitoring Well(s) # of Wells Soil Boring(s) # of borings Geotechnical # of borings <br />Out -Of -Service Well i Out -Of -Service Well Renewal 1 Cross -Connection Repair <br />New Pump A Pump Replacement Pump Repair Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br />Proposed Well Depth It Excavation in diameter -I 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 i Steel i i Plastic i i Stainless Steel i i Other <br />Grout Seal Depth ft i Neat Cement (94 lb bag/5-10 gal water) 1 1 Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method -1 Pumped : Free Fall Other Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor Other <br />Concrete Pedestal Dimensions: Width ft Length It Thick in Christy Box Stove Pipe <br />PUMP XSubmersible Turbine i. i Other HP 1 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 />JOAQUR+-COUNTY (*DINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />rDXr((RRENT AND ACTIVE WITH THE CALIFORNIA,eONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />SIGNED <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection,By <br />NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 95 <br />TITLE MAIL ,,"6x=� DATE —Z <br />I <br />■■■■■■■■■■■■■■■■■■■■■■■■■��■ <br />I <br />I- <br />Area Employee D#'444f <br />Date SPECIAL Well Permit <br />Date �WAIVER Received <br />Date <br />PE SC Received Chec Amount Da <br />Codes Info B ash Remitted <br />Permitt Invoice # <br />ervice Request # <br />Well ID# <br />42-7GS <br />� <br />31 <br />EHD 43-06 WELL /PUMP PERMIT <br />4/30/12 <br />