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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 PE IT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 18572 Carrolton Road <br /> pTY/Z,P Ripon,California <br /> CROSS STREET Yosemite Avenue APN Zity OV _PARCEL SIZE U• LAND USE APPLICATION# A <br /> �'� 864-232-8987 n <br /> OWNER NAME S&ME Inc. - Ult Tll--tir S• PHONE <br /> OWNER ADDRESS 281 Fairforest Way CITV/STATE/zIP Greenville,SC 29607 <br /> CONTRACTOR Krazan&Associates,Inc PHONE 559-348-2200 <br /> CONTRACTOR ADDRESS 215 W.Dakota Avenue CITY/STATE/ZIP Clovis,CA 93612 <br /> SUBCONTRACTOR Krazan&Associates,Inc. PHONE 559-348-2200 <br /> SUBCONTRACTOR ADDRESS 215 W.Dakota Avenue CITY/STATE/7JP CIOVIS,CA 93612 <br /> LICENSE -/C-57 n C-61 U D-09 ]Other NUMBER 499908 EXPIRATION DATE 10/31/2015 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y TOwnshl Range Section <br /> INTENDED USE D DomesticlPrivate E Irrigation/Agricultural ❑Industrial D Water Quality Monitoring Soil Sam <br /> ,Wlilliftracterizabon <br /> U Public Water System <br /> If different from Owner: Water byStern Name m r e u r <br /> TYPE OF WORK D New Well D Replacement Well /ell Alteration/Modifi t❑Monitoring Wells) #of wells Soil Bori 1 •ofrh&KE <br /> s Geotec #of bo ngs <br /> n Out-Of-Service Well a ross-C <br /> D New Pump D Pump Replacement Jim, n }� <br /> WELL CONSTRUCTION <br /> Drilling Method D Mud Rotary D Air Rotary VAuger .1 Case T�p�y �oint <br /> Proposed Well Depth 60 ft Excavation i eter M c ave!Size in diameter <br /> I I Conductor Casing in diameter / Co�nf <br /> Well Casing Diameter_m Thicknes Gauge/ASTM Schel?C astic n Stainless Steal !Other <br /> ;0 <br /> Grout Seal Depth ft eat Cement(94 lb bacitl �t�r) 5and Cement sack mixf7 gal water <br /> I Bentonite(20%solids) Other UU <br /> Grout Placement Method Pumped -1 Free Fail n Other n Retardant/Accelerator(name) <br /> PEDESTAL Installed By D Driller D Pump Contractor ❑ Other <br /> D Concrete Pedestal EDimensions:Width ft Length ft Thick in U Christy Box C Stove Pipe <br /> PUMP D Submersibleu Turbine D Other HP 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 /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> 24 HOU A A CE NOTICE RE FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> „ SIGNED TITLE Managing Engineer DATE 09/15/2015 <br /> j 7 <br /> r <br /> 1� <br /> tAl EIVED <br /> 16 2015 <br /> MENTAL HEALTH <br /> IT/SERVICES <br /> EPARTMENT USE ONLY <br /> Application Accepted By Date Areay `I • \ Employee ID# <br /> Grout Inspection By Date SPECIAL Well Permit PA "T Pump Inspection By Date WAIVER Received C <br /> Soil Boring Inspection By Date Constructed Well Depth ft pCCE1Vl-D <br /> COMMENTS �lG <br /> SEP2 2 2015 <br /> PE SC Receivedheck#/ Amount Permit/ <br /> Codes Info CashRemitted ate Service Re uest# Invoice# Weil ID# A(�f1J'N CpUN� <br /> 't3AS� .11 a2o5g5 3 4t I PDO 318 Ot+QEPAVIIMF-rm <br /> ao 4 <br /> EHD 43-06 <br /> 4/30112 WELL/PUMP PERMIT <br />