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4600 - Public Water System Program
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PR0543085
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Entry Properties
Last modified
1/31/2025 11:07:38 AM
Creation date
12/3/2020 2:33:40 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4600 - Public Water System Program
File Section
BILLING
RECORD_ID
PR0543085
PE
4633
FACILITY_ID
FA0004409
FACILITY_NAME
BIRDS NEST CHILD DEVELPMT CTR INC
STREET_NUMBER
20700
Direction
E
STREET_NAME
RIVER
STREET_TYPE
RD
City
RIPON
Zip
95366
APN
3BCOUNT20
CURRENT_STATUS
02
SITE_LOCATION
20700 E RIVER RD
P_LOCATION
99
P_DISTRICT
005
QC Status
Approved
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EHD - Public
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WELL / PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALPARTMENT 304 E WE0 vE 31O FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> � y <br /> JOB ADDRESS 2 0 7 0 0 R i vP r Ca 9 5 3 6 6 m <br /> R(7.'�r� �,,j�j CITY/Zip Ripon, <br /> CROSS STREET Etite'' �� APN l .✓ � ��� PARCELSIZEJX��'� , v <br /> v <br /> OWNER NAME Ellie Temple APASL PHONE y <br /> OWNER ADDRESS 20700 River Road TV /`LIP R3.pQn I Ca 95366 <br /> n <br /> CONTRACTOR Purviance Drillers Inc. PHONE 209-887-3554 <br /> CONTRACTOR ADDRESS P- 0. BOX 64 CITY/STATE/ZIP Linden, Ca 95236 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE N C-57 ❑C-61 ❑D-09 ❑Other 377923 NUMBER 3 7 7 9 2 3 EXPIRATION DATE 7/3 1 /0 5 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> CXPublic Water System EMIT& Bi rWS rft. t CbJ I EIPN 10pMPICI oVdifferent from Owner: ' rrAr <br /> e Number <br /> TYPE OF WORK X New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other <br /> number of wells number of borings number of borings <br /> ❑Monitoring Well(s) ❑Soil Boring(s) ❑Geotechnical o <br /> ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal <br /> ❑New Pump ❑Pump Replacement ❑Pump Repair ❑Cross-Connection Repair <br /> WELL CONSTRUCTION <br /> Drilling Method R Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth ft Excavation 1 2 in diameter R Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Ca,ipepth ft <br /> Well Casing Diameter 6__j6_ fj Thickness/Gauge/ASTM Sched (p 3P Steel ❑Plastic ❑Stainless Steel ❑Other s <br /> Grout Seal Depth �-It® ❑Neat Cement(94/b hag/5-f0gcr/water) g Sand Cement 1 03s ac sack mix/7 gal water <br /> ❑Bentonite(T6.1.solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method XI Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑Other <br /> ❑Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP ❑Submersible ❑Turbine' ❑Other HP Pump Set ft Standing Water Level ft <br /> WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other <br /> Well Diameter in Total Depth ft Depth to Water ft ❑Casing to be Perforated from ft to ftSealing Material ❑Neat Cement(94/h hug/5-/0 gal water) ❑Sand Cement sack mix/7 gal water 11Bentonite Pellets <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Placement Method ❑Pumped ❑Free Fall ❑Other <br /> ❑Complete with Mushroom Cap ft below grade ❑Complete to Existing Surface Pad <br /> I HEREBY CERTIFY THAT 1 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. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATI LAWS. <br /> IMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIG TITLE Corporate Secretary DATE 10/20/03 <br /> 07 wi-71 <br /> low 11% 1 <br /> P NN1 <br /> M1 4nrl <br /> iFN\JWU <br /> DEPARTMENT USE O`NLY <br /> Application Accepted By ' 'W`,'t"`^ Date_I ?- ,-0 Area Employee ID# <br /> `— ®� <br /> Grout Inspection By W-IJG• Date O -0-5 ❑ SPECIAL Well Permit N/qq <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Destruction Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Amount Check#/ Received Date Permit/ Invoice# Well ID# <br /> Codes Info Remitted Cash By Service Request# <br /> EHD 43-02-006 MASTER WATER WELL PERMIT <br /> 5/7/2002 <br />
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