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WELL / PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALPARTMENT 304 E WE0 vE 31O FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED � y JOB ADDRESS 2 0 7 0 0 R i vP r Ca 9 5 3 6 6 m R(7.'�r� �,,j�j CITY/Zip Ripon, CROSS STREET Etite'' �� APN l .✓ � �� PARCELSIZEJX��'� , v v OWNER NAME Ellie Temple APASL PHONE y OWNER ADDRESS 20700 River Road TV /`LIP R3.pQn I Ca 95366 n CONTRACTOR Purviance Drillers Inc. PHONE 209-887-3554 CONTRACTOR ADDRESS P- 0. BOX 64 CITY/STATE/ZIP Linden, Ca 95236 SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE N C-57 ❑C-61 ❑D-09 ❑Other 377923 NUMBER 3 7 7 9 2 3 EXPIRATION DATE 7/3 1 /0 5 GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization CXPublic Water System EMIT& Bi rWS rft. t CbJ I EIPN 10pMPICI oVdifferent from Owner: ' rrAr e Number TYPE OF WORK X 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) ❑Geotechnical o ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑New Pump ❑Pump Replacement ❑Pump Repair ❑Cross-Connection Repair WELL CONSTRUCTION Drilling Method R Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other Proposed Well Depth ft Excavation 1 2 in diameter R Open Bottom ❑Gravel Pack/Gravel Size in diameter ❑Conductor Casing in diameter / Conductor Ca,ipepth ft Well Casing Diameter 6__j6_ fj Thickness/Gauge/ASTM Sched (p 3P Steel ❑Plastic ❑Stainless Steel ❑Other s Grout Seal Depth �-It® ❑Neat Cement(94/b hag/5-f0gcr/water) g Sand Cement 1 03s ac sack mix/7 gal water ❑Bentonite(T6.1.solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Grout Placement Method XI 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 Pump Set ft Standing Water Level ft WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other 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 ❑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 I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. 1 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 COMPENSATI LAWS. IMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS SIG TITLE Corporate Secretary DATE 10/20/03 07 wi-71 low 11% 1 P NN1 M1 4nrl iFN\JWU DEPARTMENT USE O`NLY Application Accepted By ' 'W`,'t"`^ Date_I ?- ,-0 Area Employee ID# `— ®� Grout Inspection By W-IJG• Date O -0-5 ❑ SPECIAL Well Permit N/qq Pump Inspection By Date ❑ WAIVER Received Destruction Inspection By Date Constructed Well Depth ft COMMENTS PE SC Amount Check#/ Received Date Permit/ Invoice# Well ID# Codes Info Remitted Cash By Service Request# EHD 43-02-006 MASTER WATER WELL PERMIT 5/7/2002