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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 PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> N <br /> JOB ADDRESS 22627 FREDERICK RD CITY/ZIP RIPON, 95366 m <br /> 7� V <br /> CROSS STREET W. RI PON RD APN U PARCEL SIZE _LAND USE APPLICATION# m <br /> m <br /> OWNER NAME KEVIN KIRKPATRICK PHONE 209.604.5297 <br /> OWNERADDRESs 22627 FREDERICK RD CTY/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 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 DomestiC/PrlVate Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water System Name on ame orPhoneum r b_ •ry. <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other �M�w'•r <br /> MonitoringWell(s) #of wells SoilBoring(s) 0o borings Geotechnical #ofbodngs <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump X Pump Replacement Pump Repair Raise Well Casin i! <br /> WELL CONSTRUCTION %JO y 2018 <br /> Drilling Method Mud Rotary Air Rotary Auger Cable Tool i Push Point Other `- <br /> Proposed Well Depth ft Excavation in diameter i Open Bottom Gravel Pack/Gravel SizeF O(JN� <br /> Conductor Casing in diameter / Conductor Casing Depth ft OF/J ) ,ii <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad Steel i Plastic i Stainless Steel Other TMFNT <br /> Grout Seal Depth ft i Neat Cement(94 lb bag/5-10 gal water) !Sand Cement sack mixl7 gal water <br /> Bentonite(20%solids) i Other <br /> Grout Placement Method i Pumped Free Fall i Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width ft Length it Thick in Christy Box Stove Pipe <br /> PUMP XSubmersible Turbine Other HP__-1_5— Pump Set R(1 it 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 /> C T AND A IVE WITH TkiE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> ORKE COMP \ATIONION A <br /> I � A A NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697� <br /> SIGNED TITLE 1' ,' ''_ DATE t <br /> N <br /> E <br /> S <br /> VD aRENT US O LY <br /> Application Accepted By Date/V/3/Q Area Employee ID#j/� <br /> Grout Inspection By Date V11PECI L Well Permit <br /> Pump Inspection By + Date L WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC I Received eck#/ Amount Permit/ <br /> Codes Info B as miffed Date Service Request# Invoice# Well ID# <br /> lowew ';'k-1k <br /> EHD 43-136 WELL/PUMP PERMIT <br /> 4!30/12 <br />