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WELUPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL 209 953-7b97 FOR INSPECTIONS CAVI K=0 7 TEAR I•KUM UAIL lbbULU <br />JOB ADDRESS <br />CROSS STREET <br />20021 S. JACK TONE RD (200 33) <br />C,,,ZZlP RIPON 95366 <br />PARCEL SIZE"' LAND USE APPLICATION If <br />H WY 99 APN '12-T 0:W b <br />OWNER NAME <br />RICK HOGAN <br />PHONE 541.6038 <br />OWNER ADDRESS <br />20021 S. JACK TONE RD <br />CI Y/STATEIZIP RIPON, CA 95366 <br />CONTRACTOR <br />N & S IRRIGATION, INC <br />PHONE 209.599.3456 <br />CONTRACTORADDREsS 215W, MAIN STREET <br />CITY/STATE/ZJP RIPON- CA, 95366 <br />SORCnMLnACTOR <br />PHONE <br />)R ADDRESS <br />C-57 C-61 D-09 <br />CITY/STATE/ZIP <br />NUMBER 662732 EXPIRATION DATE 01/31/19 <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Rangfi Section <br />TENDED USE X Domestic/Pnvale Irrigation/Agricultural Induslnal Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System <br />11 different from Ownerwater Systern Nam Contact Nam or Phone Nuffifier <br />TYPE OF WORK New Well Replacement Well Well ARerationlModification Other <br />Monitoring Weil(sl__ # of wells Soil Bonng(s) <br />a of borings Geotechnical ___ - # of bodrrea <br />e,'glut-OfService Well Out -Of -Service Well Renewal Cross -Connection Repair <br />t7 MPw Pumn & Pumo Renlacement Pumo Reoair 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 Sched Steel Plastic Stainless Steel Other <br />Grout Seal Depth It 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 ft Length It Thick in Christy Box Stove Pipe <br />PUMP XSubmersible Turbine Other HP 2 Pump Set ft Standing Water Level R <br />I HEREBY CERTIFYTHAT1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />CURRENnANDN CTIV�DIWITH E HESTATE <br />AT FORNIA CQNTRACTO SLAWS. AND RULES NSTATEULATIONS. I ALSO CERTIFY THAT LICENSE BOARD AND THAT AM INYREQUIRED COMPLIANCE LICENSE <br />ALL <br />Application Accepted By' <br />Grout inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />REQUIRED FOR <br />/AINSPECTIONS <br />J-- PLEASE CALL (209) 53- 97 <br />TITLEI \� 1'n/ \ L/�/' l V DATE I <br />DEPARTMENT USE ONLY <br />_ Date <br />Date/ Date <br />Date <br />D <br />a <br />Area'qj 11 -1 Employee ID# Ahm17 6-1 <br />SPECIAL Well Pemtit <br />WAIVER Received <br />Constructed Well Depth R <br />PE <br />Codes <br />SC <br />Info <br />Received Check#/ <br />B Cash <br />Amount a <br />Remitted <br />PerrniV Invoice# Well IDN <br />Service Re Ut # <br />43%0 <br />osv <br />as�� <br />3 I <br />EHD 43-09 WELL (PUMP PERMIT <br />4130112 <br />