Laserfiche WebLink
j2 <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CA 209 953-7697 FOR INSPECTIONS EXPIRES 1 WR FR DATE ISSUED <br /> r�I <br /> JOB ADDRESS 11960 W. RIPON RD / '''j(I�—, CITY/ZIP /J a <br /> CROSS STREETS. OLIVE AQN'2r:/;I-Zbu'�¢�ARCEL SIZELAND USE APPLICATION# <br /> OWNER NAME JOHN�/IEIRA � I _ PHONE 209.918.9794 w <br /> OWNER ADDRESS 11960 W. RIPON RD 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 CITYISTATE/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 DomeStlC/Pnv to Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water System Name Uontact Name or Phone Nurnoer <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification i Other <br /> Monitoring Well(s) #of wells Soil Boring(s) #of horings Geotechnical #of borings <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 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 Sched Steel i Plastic ! Stainless Steel i 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 ft Length ft Thick in Christy Box Stove Pipe <br /> PUMP XSubmersible Turbine Other HP___L_ Pump Set__BD_ft Standing Water Level_27 ft <br /> I Y CERTIF THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN I� <br /> OAQUI COON RDINANCE , STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT ND C IVE WIT E CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> S COM E S ON <br /> 4 HO AD OTICE REQUIRED FOR�INSPECTIONS <br /> --/PLEASE CALL(209)9533-7697 <br /> SIGNED TITLE ` '��IC� DATE <br /> N <br /> E <br /> S <br /> REC <br /> NOV 0 <br /> EWVIROWE <br /> pERMlris <br /> PAYMENT t <br /> REGEIVED <br /> 2017 V Z 7 EP TMENTit E N L Y <br /> NO JOAnuIN�uKlyApplication Accepted By Date.G G � Area Employee ID#J! I� <br /> `�ENytRONMEMT►J Grout Inspection By Date *SPECIALWell Permit <br /> HEALTH DEPkR-r%l Pump Inspection ByJI)LADate WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received heck Amount Date Permit/ Invoice# WeIIID# <br /> Codes Info B ash Remitted Service Request# <br /> o� �Z <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4130/12 <br />