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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 /> ST <br /> JOB ADDRESS 18601 E RIVER RD CITY/ZIP RIPON, 95366 <br /> CROSS STREET MURRPHY RD APN Ul–VO PARC EL SIZE"LAND USE APPLICATION# <br /> H <br /> OWNER NAME FRANK VANDER PLATTS PHONE 599.2325 <br /> OWNER ADDRESS 18601 E RIVER 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 I 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/Private I Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water Systerh Name GontaCt Name or Phone NUMber <br /> TYPE OF WORK New Well _ Replacement Well ❑Well Alteration/Modification ❑Other <br /> Monitoring Well(s) #of wells LI Soil Boring(s) #of borings I I Geotechnical #of borings <br /> ut-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> New Pump Pump Replacement F1 Pump Repair n Raise Well Casing <br /> WELL CONSTRULftN <br /> Drilling Method - Mud Rotary Air Rotary Auger i I Cable Tool ❑Push Point r Other <br /> Proposed Well Depth ft Excavation in diameter 7 Open Bottom -1 Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad :1 Steel ❑Plastic 11 Stainless Steel ❑Other <br /> Grout Seal Depth ft i I Neat Cement(94 lb bag/5-10 gal water) a Sand Cement sack mixR gal water <br /> Bentonite(20%solids) L 1 Other <br /> Grout Placement Method L Pumped I.Free Fall ❑Other 7 Retardant I Accelerator(name) <br /> PEDESTAL Installed By, L Driller I Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width ft Length ft Thick in - Christy Box -1 Stove Pipe <br /> PUMP XSubmersibfel_ Turbine n Other HP Pump Set ft 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 /> COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> URRENT ND AC E WIT THE ALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> W ERS OMPE TION L WS <br /> IMU O R V N ICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGN TITLE DATE. 7 <br /> N E w-, yi5 <br /> S ; <br /> Y , 2017 <br /> ENTAL HEALTH <br /> kAULVTI 10IT/3E V!CES <br /> RETE QED <br /> Y302017 <br /> hmR'ONM CD'U�1j <br /> P RTMENT USE 99NLY LhDFR4R11 <br /> Application Accepted By a Date� Area Employee ID# b <br /> Grout Inspection By Date SWell Permit <br /> Pump Inspection By Date 1') ..YI 1 11 1 3— ❑ WAIVER Received <br /> Soil Boring Inspection By Date�f Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received a #/ Amount Date PermlU Invoice# Well ID# <br /> Codes Info B Remitted Service Reguest# <br /> za b�D z� r7 S A- 000313y1 <br /> EHD 43-08 WELL/PUMP PERMIT <br /> 4/30/12 <br />