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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 GALL ZUV) U0J-1bVf FUKINSPt(; IIUNS CArimr-a I T tAK FKUM L/A I t IbZUCU <br />JOB ADDRESS <br />CROSS STREET <br />20021 S. JACK TONE RD l QUO 5'� <br />CITYIZIP RIPON 95366 <br />PARCEL SIZE' o 1 LAND USE APPLICATION # <br />/j <br />H WY 99 APN ^ O �y <br />OWNER NAME <br />RICK HOGAN <br />PHONE 541.6038 <br />OWNER ADDRESS <br />20021 S. JACK TONE RD <br />CITY/STATE/ZIP RIPON, CA 95366 <br />CONTRACTOR <br />N & S IRRIGATION INC <br />PHONE 209.599.3456 <br />CONTRACTOR ADDRESS 215 W MAIN STREET <br />CITY/STATEIZIP RIPON, A, 95366 <br />SUBCONTRACTOR <br />_ PHONE <br />SUBCONTRACTOR ADDRESS <br />LICENSE C-57 C-61 <br />CITY/STATE/ZIP <br />D-09 XOther C10 NUMBER 662732 EXPIRATION DATE 01/31/19 <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township _ Range Section <br />ITENDED USE X 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 am or Phone Number <br />TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br />Monitoring Well(s)__" # of wells Soil eorino(s)#of borings Geotechnical #of borings <br />,-,*ut-Of-Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />/Y New Pmmn & Pumn Renlaremenf PumO Renair Raise Well Casino <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 Schad Steel Plastic Stainless Steel Other <br />Grout Seal Depth ft Neat Cement (94 lb bag/5-10 gal water) Sand Cement sack mixll 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 ft Thick in Christy Box Stove Pipe <br />PUMP XSubmersible Turbine Other HP 2 Pump Set ft Standing Water Level ft <br />1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />COUNTY DINANCES, ST TE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENY\AND AC IV WITH HE IFORNIA C TRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />OR ERSICOMPE S TION LA S. <br />NI U 4 OUR A A CE ICE REQUIRED FOnR/,11IN//.S�PE�CJt�TI/�O/N7�ST-/P^/LEASE CALL (209) 53- 97 <br />DATE <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />EPARTMENT USE ONLY <br />w Date <br />Date� <br />/ Date <br />Date <br />N <br />Area q 4 -t Employee ID# Ah,,Y) f, G/ <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth ft <br />PE <br />Codes <br />SC <br />Info <br />Received Check#/ <br />By Cash <br />Amount <br />Remitted <br />a <br />Permitl Invoice # <br />Service Request # <br />Well ID# <br />4390 <br />vsu <br />37 <br />t0 <br />q <br />EHD 43-06 WELL /PUMP PERMIT <br />4/30/12 <br />