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RECEIVED <br /> t WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISS 1 201$ <br /> JOB ADDRESS 21422 CARROLTON RD /, crrymp RIPON 95366 � m I <br /> CROSSSTREET RAP[ I n RIS APN Z*S-7- � � PARCEL SVE( LAND USE APPLICATION# L1\�,((Z�)1 �•",`'�� 11�/,�-,'I `"� <br /> OWNER NAME C•ReC� FARMS �1ZLP5, COAZI60 PHONE 209.531.3572 1'311ENT <br /> OWNER ADDRESS 21602 S CARROLTON RD CrTY/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 CITYISTATEMP <br /> LICENSE C-57 L C-61 D-09 XOthef C 10 NUMBER 662732 EXPIRATION DATE 01/31/19 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br /> INTENDED USE Domestic/Private -- Irrigation/Agricultural C Industrial L Water Quality Monitoring ❑Soil Sampling/Charactenzation <br /> Public Water System <br /> If different from Owner: Water 5YSIOM Nam Contact Name or one Number <br /> TYPE OF WORK New Well . Replacement Well l Well Alteration/Modification -1 Other <br /> Monitoring Well(s) #of wells _I Soil Boring(s) u of borings Geotechnical of borings <br /> Out-Of-Service Well ❑Out-Of-Service Well Renewal F Cross-Connection Repair <br /> X New Pum - Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary - Auger n Cable Tool Push Point i 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 Schetl I Steel ❑Plastic L Stainless Steel ❑Other <br /> Grout Seal Depth ft -Neat Cement(94 lb bag/5 10 gal water) -i Sand Cement sack mixf7 gal water <br /> Bentonite(20%solids) I I Other <br /> Grout Placement Method f7 Pumped C Free Fall L Other 1 Retardant/Accelerator(name) <br /> PEDESTAL Installed By -Driller Pump Contractor Other <br /> Concrete Pedestal-Dimensions:Width It Length ft Thick in - Christy Box -1 Stove Pipe <br /> PUMP Submersible.- Turbine Other HP 334 Pump Set___aQ_ft Standing Water Level___4$_ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOA OUNTY O NANCES, TATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> NT D ACTT WITH TH C IFORNIA CON CTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> RSC MPENS O LAWS <br /> H R AN E E REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-776/97 <br /> 1 SIGNED TITLE " t\La'el:ILS DATE �' ✓✓� �� <br /> N <br /> E <br /> S <br /> R <br /> P�v1N CO <br /> SP�Q N�EpAR <br /> N <br /> / EPA TMENT U E N Y / <br /> Application Accepted By 1 Date t! Area Employee ID#�CP <br /> Grout Inspection By Date ❑ PECIAL Well Permit <br /> I <br /> Pump Inspection By Date v :1 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received WqCWAmount Date Permit/ Invoice# Well ID# <br /> Codes Into B Remitted Service Request# <br /> EHO 43-06 WELL/PUMP PERMIT <br /> x30/12 <br />