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14WELL/PUMP PERMIT RECEIVED <br /> y <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 ISSU 1 20/4 <br /> JOB ADDRESS 20020 N RIPON RD / Z CITY/ZIP m I Iv <br /> CROSS STREET �T SC L APN�J� 1��/� PARCEL$IZE� AND USE APPLICATION# ENVIRON� A E I v 'r,L I I 1,t`r1 i <br /> OWNER NAME BOB MADSEN PHONE 541.4311 Dl' 9kIZIINIEN'I <br /> OWNER ADDRESS 20020 N RIPON RD CITY/STATE/ZIP RIPON, CA. 95366 <br /> CONTRACTOR N &S IRRIGATION, INC PHONE 209.599.3456 <br /> CONTRACTOR ADDRESS 215W- MAIN STREET CITY/STATE/ZIP RIPON CA. 95366 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C-57 I C-61 D-09 XOther C10 NUMBER 662732 EXPIRATION DATE 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/Charactenzalion <br /> Public Water Swnerystem w` <br /> If different from OWater bys em ame Contact Nam or Phone Number <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other CF Fir <br /> MonitoringWell(s) #of wells SoilBoring(s) #ofbonngs .Geotechnical #ofbon ngs <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair MA v D <br /> New Pump X Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION • 20 <br /> Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other (��N �� <br /> C0 <br /> Proposed Well Depth ft Excavation in diameter Open Bottom i Gravel Pack/Gravel Size t � T <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched Steel i i Plastic i Stainless Steel i Other MFj1/� <br /> Grout Seal Depth ft i Neat Cement(94 lb bag15-10 gal water) I i Sand Cement sack mixr7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped Free Fall 1 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 Pump Set 100 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 /> JOAQUI UNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CUR T A D ACTI WITH TH CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WO KERS C MPEN ATION AW <br /> UM O R OTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)`9153-7e697 <br /> SIGNED:7" TITLE I' 7 �Iy�'r"r`��{-XLH DATE `4,10-( V <br /> N <br /> E <br /> S <br /> DE ARTMENT USE ONLY <br /> Application Accepted By DateAt __Q Area T/"l / Employee ID#10�� <br /> Grout Inspection By nIADate �SPECIA�L WCII Permit <br /> Pump Inspection By Date I _ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received ec Amount Date Permit/ Invoice# Well ID# <br /> Codes Into B ash Remitted Service Request# <br /> WIP0038 <br /> EH D 43-06 WELL/PUMP PERMIT <br /> 4130112 <br />