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IL I WELL / PUMP PERMIT SAN J QUIN CO NVrVIRONMENTAL HEALTH D�IMENT 304 E WEBERS°D - TOCWRF 5809)468-3420 NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIR S 1 VMISSUED JOB ADDRESS 20700 Rivt-r Read crrY/zIP Ripon Cal 95366 > CROSS STREET Van Allen Rd. APN 245-230-36 PARCEL SIZ� s . F m OWNER NAME Ellie Temple (Bird' s Nest _h;'1 d D -VP1 npment ) PHONE OWNERADDRESS 20700 River Road CITY/STATE/ZIP Ripon, Ca 95366 CONTRACTOR Purvinace Drillers, INC. PHONE 209-887-3554 CONTRACTOR ADDRESS P• 0. BOX 64 CITY/STATE/ZIP L i nden, CA 95236 SUBCONTRACTORIF\\ PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE XC-57 ❑C-61 ❑D-09 ❑Other NUMBER EXPIRATION DATE GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization ❑Public Water System If different from Owner. Water System Name Contact Name or one um er TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other number of wells number of borings number of borings ❑Monitoring Well(s) ❑Soil Boring(s) 11 Geotechnical ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal New Pump ❑Pump Replacement ❑Pump Repair ❑Cross-Connection Repair WELL CONSTRUCTION Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other Proposed Well Depth ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter ❑Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other Grout Seal Depth ft ❑Neat Cement(94 lb hug/S-/0 ga/water) ❑Sand Cement .sack mix/7 gal water ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑Other ❑Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe PUMP Submersible ❑Turbine ❑Other HP-1--1 /2 Pump Seth ft Standing Water Level -45 ft WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other Well Diameter in Total Depth ft Depth to Water ft ❑Casing to be Perforated from ftto ft Sealing Material ❑Neat Cement(94/b bug/5-/0ga/water) ElSand Cement suck mix/7 gal water ❑Bentonite Pellets ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Placement Method ❑Pumped ❑Free Fall ❑Other ❑Complete with Mushroom Cap ft below grade ❑Complete to Existing Surface Pad 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. �� l M 2 U�ADV�ANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 SIC TITLE Corporate Secretary DATE 12/11 /03 14 At I Y 17, 1 S KIK A Hi AJH EP kRIME 3a. PARTMENT USE NLY Application Accepted By Date Area Employee IDA -7V /l// Grout Inspection By ,� II Date 22 SPECIAL Well Permit "!/M Pump Inspection By IV G1 Date (0-l`b ❑ WAIVER Received Destruction Inspection By Date Constructed Well Depth ft COMMENTS PE SC Received rec!l# Amount Date Permit/ Invoice Al Well ID# Codes Info By %ZnC1'S-h Remitted Service Request t/ 5 S .c' b-7 7 EHD 43-02-006 ) MASTER WATER WELL PERMIT 12/6/2002 {