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WELL/PUMP PERMIT <br /> RECEIVED <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 ISSjJjjj1-1Ay+I 13[", <br /> I+ 2018 <br /> JOB ADDRESS CITY/zip RIPON 95366 ` <br /> CROSS STREET .JACK TONE RD APN V,I 0 - t, PARCEL SIZE el— LAND USE APPLICATION#�N rr 1 R �I N 3,N NTA 1, 11 E A L1 H <br /> m <br /> OWNERNAME V M HULLING 1, <br /> �V�C+ PHONE 209470 7613 1) V.,90 KILI <br /> HW .,Nl�( A N <br /> OWNER ADDRESS 12999 E Y 120��06 In/I tN CITY/STATEIzIP 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 EXPIRATION DATE 01/31/19 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section <br /> INTENDED 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 contact ame or one Number <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other A <br /> Monitoring Well(s) #of wells Soil boring(s) #of borings Geotechnical #of borings ��� +�N� <br /> Out-Of-Service Well Out-Of-Service Well Renewal i Cross-Connection Repair zVA <br /> OAD <br /> New Pum X Pum Replacement Pum Repair Raise Well CasingAMY L <br /> WELL CONSTRUCTION /, <br /> Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other Oq <br /> Proposed Well Depth ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diaet RQ(J/NC v <br /> Conductor Casing in diameter / Conductor Casing Depth ft /� NMF OVNry <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other �Fpqrk� <br /> Grout Seal Depth ft Neat Cement(94/b bag/5-10 gal water) Sand Cement sack mixf7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By 1 Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width ft Length ft Thick in Christy Box 1 Stove Pipe <br /> PUMP XSubmersible Turbine Other HP__5_ Pump Set 1 QC ft Standing Water Level <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOA �UNTY O INANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CU ENT A D ACTT WITH THg CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WO KERS COMPEN ANON L W�IV <br /> UM U ��TICE REQUIRED FOR IN/�SPECTI/O'NSP)LEASE CALL(209)�9r153 7697 <br /> MYISIGNED TITLE 1\/,n 1 DATE I,�y <br /> N <br /> E <br /> S <br /> ftt✓ <br /> `P RTMENT USE OILY <br /> ��//�' <br /> Application Accepted By Date IF Area <br /> -� Employee ID#L`J_EL�L� <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date 102WT WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received a #/ Amount Date PermiU Invoice# Well ID# <br /> Codes Info B Remitted Service Request# <br /> 2&341 0003B273 <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4/30/12 <br />