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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 L 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS <br /> 23223 S Austin Road CITY/ZIP I Ri ton.CA <br /> CROSS STREET ( APN 226-150-027D <br /> . rI _ PARCEL SIZ AND USE APPLICATION <br /> OWNER NAME �C1:1 1;rse rV u'Gmt/ � � PHONE # pm <br /> rn• <br /> OWNERADDRESS •'3223 S Austin Road CITY/STATE/ZIP Ripon,California <br /> CONTRACTOR kr.'tan 3.�55a1'iae;5 In,; PHONE 559.3482200 <br /> CONTRACTOR ADDRESS 1,,',', D[ikutn Ave1ILI,! CITY/STATE/ZIP Oluv,,,California 93612 <br /> SUBCONTRACTOR Kc1.nn!­ASaciates.Inge PHONE 59.348.2200 <br /> SUBCONTRACTOR ADDRESS `1"4V Dakota/\vanue CITY/STATE/ZIP Clovis,California 93612 <br /> LICENSE /C-57 C-61 D-09 Other NUMBER 499908 EXPIRATION DATE 10.312018 <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private Irrigation/Agricultural Industrial 7 Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells Soil Boting(s) #of borings ,f Geotechnical 3 8 of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair a"i1 <br /> New Pump Pump Replacement Pump Repair Raise Well Casio <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary /Auger Cable Tool Push Point Other <br /> Proposed Well Depth j45 -170' it Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth fl <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br /> Grout Seal Depth(K�ri O ft /Neat Cement(941b bag/5-10 gal water) Sand Cement sack mixR gal water <br /> Bentonile(20%solids) Other <br /> Grout Placement Method Pumped Free Fall Other t% Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller IPump Contractor Other <br /> Concrete Pedestal Dimensions:Width fl Length ft Thick in Christy Box Stove Pipe <br /> PUMP Submersible_ Turbine 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 /> 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 /> ,LVIINIMUM 48 UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE Managing Fngmeer DATE 0926.2018 <br /> MINT <br /> ED <br /> 82018 <br /> NTUN�' <br /> AC <br /> 71, <br /> PA TMENT U E O L / / <br /> Application Accepted By D to Area'�' Employee ID# �� <br /> Grout Inspection By Dale SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date '✓ ( Constructed Well Depth ft <br /> COMMENTS <br /> PE SC ReceivedCheck Amount Date Permit/ Invoice# Well ID# <br /> Codes Info S Ram eryic Re oast# <br /> L7 S <br /> EHC 43-00 reused 4114/18 WELL/PUMP PERMIT <br />