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JOB ADDRESS <br /> 744 N Jack Tone Road, Ripon, CA ciwzie Ripon/95366 <br />CROSS STREET Canal Drive APN 25966058 PARCEL SIZE 1.11 ac LAND USE APPLICATION* <br />OWNER NAME <br /> Village Investment Partners, I..P. P HONE 415-227-2208 <br />OWNER ADDRESS 940 Emmett Avenue, Suite 200 <br />CITY/STATE/ZIP Belmont/California/94002 <br />CONTRACTOR <br /> Salem Engineering Group, Inc. <br />PHONE 559-271-9700 <br />CONTRACTOR ADDRESS 4729 West Jacauelvn Avenue crry/srAnizip Fresno, California 93722 <br />SUBCONTRACTOR/CONSULTANT Salem Engineering arouo, Inc. PHONE 559-271-9700 <br />SUBCONTRACTOR/CONSULTANT ADDRESS 4729 West Jacquelyn Avenue <br />CITY/STATE/ZIP Fresno, California 93722 <br />LICENSE • C-57 C-G1 D-09 Other <br />BILLING PARTY: OWNER CONTRACTOR <br />NUMBER 970772 EXPIRATION DATE 3/31/2022 <br />SUBCONTRACTOR/CONSULTANT <br />.4" <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCK-TON CA 95205 -6232 (209)468-3420 <br />NON-REFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />DOMESTIC WELL SAMPLING: General Mineral/Conform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE Domestic/Private Irrigation/Agricultural Industrial 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 Boring(s) 8 *of bonngs . Geotechnical 4 ol bonngs <br />Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br />New Pump Pump Replacement Pump Repair Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method Mud Rotary Air Rotary 4 Auger Cable Tool Push Point Other <br />Proposed Well Depth n/a ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter In Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel - Other <br />Grout Seal Depth 5 to 25 ri -.Neat Cement (94/b bag/5-10 gal water) Sand Cement sack mod7 gal water <br />, Bentonite (20% solids) Other <br />Grout Placement Method • Pumped V Free Fall - Other Tremmie Retardant / Accelerator name) <br />SIGNED :SS3HCIati 31IS PEDESTAL Installed By Driller Pump Contractor Other <br /> <br />Concrete Pedestal Dimensions: VVidth ___ ft Length ft Thick 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 />ADVANC,fr ••!tt'i t)-j?..S`f .,,,.r)L3 <br />T1-LE Geotechnical Staff Engineer DATE 1/12/2020 <br />P,4 <br />RE_?-2 '"NT c <br /> Z./ VED <br />JA 6 2021 <br />J DA DLj <br />NV / O'vr" C(DUNTy <br />EP4ENTAL <br />ARYMENT <br />SA <br />A <br />DEPARTMENT USE ONLY <br /> <br />Application Accepted By Date 1/01 Sid ) Area P• <br /> Employee 10# - <br /> <br />Grout Inspection By C4e/r4 Date 2-1 i2-024 SPECIAL Well Permit <br /> <br />Pump Inspection By Date <br />WAIVER Received <br /> <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />PE <br />Codes <br />SC <br />Info <br />Received Check#f <br />Cash <br />Amount <br />Remitted Date Permit/ <br />erv t # Invoice # Well ID# <br />Li 14,i i'-', D Gli --- i/jSf.4- -, 1::,.:,;i. '‘-' I J. 4 <br />Ftegue <br />fl VI kuiice <br />IP ' <br />t <br />EHD 43-06 5/11/2013 <br />&11 <br />VVELL /PUMP PERMIT