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W LU <br />/ _� <br />CV <br />V sit <br />aw Z <br />G <br />oa <br />UZ <br />W <br />z <br />00 <br />� LU <br />V/ L' <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />nIVIV-KtI-UNUAbtLt t'tKMI I L ALL (LUS) 1104-10VI t -UK INSPECTIONS t_AYIKLb 7 YEAR FROM DATE ISSUED <br />JOB ADDRESS 14057 CLINTON SOUTH Vt- CITY/ZIP RIPON, 95366 <br />CROSSSTREET JACK TONE RD APN ' D—PARCEL$IZE/'?- -7 NP USE APPLICATION# <br />OWNER NAME ^7 N G HfII k <br />OWNER ADDRESS :7 07- CITY/STATE/ZIP BRENTWOOD, CA. 94513 <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 <br />LICENSE C-57 C-61 D-09 <br />CITY/STATE/ZIP <br />XOther C 1 0 NUMBER 662732 EXPIRATION DATE 01/31/19 <br />GEOGRAPHICAL INFORMATION: Coordinates Y Township_ Range Section <br />INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System <br />If different from Owner: Water System Name on ac ame or one NUMIDer <br />TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br />Monitoring Well(s) # of wells Soil Boring(s) #of borings Geotechnical If of borings <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />n <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 Other <br />Grout Seal Depth ft Neat Cement (94 Ib bag/5-10 gal water) Sand Cement sack mixl7 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 It Thick in Christy Box Stove Pipe <br />PUMP XSubmersible. Turbine Other HPPump Set 8�r ft Standing Water Level 39, ft <br />1 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 />CU AND A IVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />W KER OM N AT ON WS. <br />MI IM 24�t��E NOTICE REQUIRED FOR INSPECTIONS <br />- PLEASE CALL (209)3-76 7 <br />$IGNE TITLE <br />M711r/r�G eezl DATE ' <br />/41 PA MUS�Y <br />ate <br />Application Accepted By ' ate <br />Grout Inspection By Date <br />Pump Inspection By Date <br />Soil Boring Inspection By Date <br />COMMENTS <br />fn <br />1 <br />D <br />0 <br />0 <br />m <br />N <br />Area _�y� Employee ID#�� <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth ft <br />PE SC Received I Check#/ <br />Codes Info B Cash <br />Amount <br />Remitted <br />Date <br />Permit' <br />Service Request# <br />Invoice # Well ID# <br />0 zsss7 <br />EHD 43-06 <br />4130112 <br />WELL /PUMP PERMIT <br />b <br />