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RECEIVED <br /> WELL/PUMP PERMIT ,, <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(203429 1 42018 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED 1 <br /> JOB ADDRESS X5947 EtIGENIA AVE CITY/ZIP RIPON SLS, �1RONNII'. FA 1, 1Il'-Ah f1l <br /> CROSS STREET MURPHY RD APN 1146'1 L"I-� PARCEL SIZELdlo—LAND USE APPLICATION# DEP 1 R I]E <br /> m <br /> OWNER NAME CHARLES TR IA ,r. PHONE 408.307.8997 <br /> OWNER ADDRESS 15947 EUGENIA AVE 1Fh'96 10� CITY/STATE/ZIP RIPON CA 95366 <br /> CONTRACTOR N &S IRRIGATION, INC PHONE 209.599.3456 <br /> CONTRACTOR ADDRESS 215 W. MAIN STREET CITY/STATE/ZIP RIPON, CA, 95366 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <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 /> INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone NUMDer <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells Soil Boring(s) #of borings Geotechnical #of todngs <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump X 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 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 lb 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 ft Thick in Christy Box Stove Pipe <br /> PUMP XSubmersible Turbine Other HP__J_ Pump Set Rn ft Standing Water Level___46_ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> J N COUNTY DINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> OU AND A TIVE WITH TH CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> RKER COMP SATIOF�N�=E <br /> INIMU 2 REQUIRED FORINSPECTIONS PLEASE CALL(209)953-7697 <br /> SIGNED TITLE DATE <br /> I <br /> N <br /> E <br /> S <br /> ppY <br /> E M <br /> R�CE�VAj <br /> MAy14 I � <br /> �oAa��r► <br /> S�P�F�A►-[H 1DEp <br /> 3 <br /> DE ARTMENT USE NLY <br /> Application Accepted By Date Area Employee ID# G/ <br /> Grout Inspection By Date PECIAL Well Permit <br /> Pump Inspection By 'NAi Data E WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received aAmount Date Permit] Invoice# Well ID# <br /> Codes Info 8 s Remitted Service Request# <br /> ; <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4/30/12 <br />