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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)4683420 <br /> ' NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> French amp Rd <br /> JOB ADDRESS CITY/ZIP Ripon 95366 <br /> m <br /> CROSS STREET T�7� F-il.. <br /> APN 203-080-23 PARCEL SIZE O 4KANO USE APPLICATION <br /> rY # O <br /> OWNER NAME en_Chang Su PHONE 209-402-8656 <br /> OWNER ADDRESS <br /> 4 Paquerette Cir CITY/STATE/LP Modesto, CA 95356 <br /> CONTRACTOR Purviancd Drillers , Inc PHONE 209-887-3554 <br /> CONTRACTOR ADDRESS P O B o x 64 CITY/STATEJLP Linden,C a 95236 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATEMP <br /> LICENSE EXC-57 D C-61 7 D-09 D Other NUMBER 377923 EXPIRATION DATE 7/3 1/19 <br /> DOMESTIC WELL SAMPLING:L General Mineral/Coliform Bacteria(4391)L Dibromochloropropane(4392)-j Arsenic(4393) <br /> INTENDED USE ><DomestictPrivate _Irrigation/Agricultural n Industrial D Water Quality Monitoring n Soil Sampling/Characterization <br /> U Public Water System A� <br /> If different from Owner. Water System Name Contact Name or Phone Number �•i �` <br /> TYPE OF WORK D New Well Replacement Well C Well AlteratiordModification D Other �� ��r <br /> D Monitoring Well(s) #of wells D Soil Boring(s) *Of ba"11QS a Geotechnical 0 of borings / �� I <br /> D Out-Of-Service Well G Out-Of-Service Well Renewal L Cross-Connection Repair ` D <br /> n New Pump n Pump Replacement n Pump Repair n Raise Well Casing + <br /> WELL CONSTRUCTION R, 08 ?0�9 <br /> Drilling Method Mud Rotary n Air Rotary n Auger D Cable Tool D Push Point n Other <br /> Proposed Well Depth ft Excavation 14 N in diameter X Open Bottom L Gravel Pack/Gravel Size in Qi RQ(JAN COU <br /> n Conductor Casing�/ in diameter / Conductor Casing Depth ft D p44'E r' �7y <br /> Well Casing Diameter in Thickness/Gauge/ASTM Schad ?(Steel ❑Plastic L Stainless Steel ❑Other ;RIV At <br /> Grout Seal Depth /00 ft J Neat Cement(94/b beg(5-10 gar water) )(Sand Cement sack rnixr7 gal water <br /> L Bentonite(20%solids) L Other <br /> Grout Placement Method YiPumped D Free Fall ❑Other D Retardant/Accelerator(name) <br /> PEDESTAL Installed By D Driller 7 Pump Contractor n Other <br /> ❑Concrete Pedestal LDimensions:Width ft Length ft Thick in n Christy Box ❑Stove Pipe <br /> pEu to D SubmersibleD Turbine 7 Other HP Pump Set ft Standing Water Level ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPUCA71ON 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 /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> INI M 24 D NCE NOTICE REQUIRED FOR INSPECTIOSectary <br /> S-PLEASE CALL(209)953-7697 <br /> SIGN TITLE C o r p o r e c t a r y DATE 2/8/19 <br /> t <br /> e 1 <br /> t k <br /> EP RTMENT USE ONLY f/ <br /> Application Accepted By Date D� Area 4 Employee ID# �SI-e44& <br /> Grout Inspection By Date ❑ SP CIAL Well Permit <br /> Pump Inspection By Date [3 WAIVER Received <br /> Soil Boring Inspection By 1 Date Constructed W 11 Depth ft <br /> C4VMMENTS �jy�S+-1V�2�r �� Yt PO dS o ✓i�l� 9t /) <br /> i <br /> PE SC Received (Check"J� Amouru ate Pemtdl Invoice# Well IN <br /> Code Info �C011 Remitted ?at! Service R uest# <br /> p Z/7S 1 wyl 17 <br /> 3 <br /> EHD43-06 =1118 WELL(PUMP PERMIT <br />