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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95206 -6232 (209) 468-3420 <br />NON-REFUNDABLE PERMIT www.s _ ov.or,/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />Jos ADDRESS 22640 S. Murphy Road Clyyaip Ripon/95366 <br />CROSS STREET Colony Road APN 245-190-45 PARCEL SIZE LAND USE APPLICATION A <br />OWNER NAME Kamps Colony Road Prop ll LP PHONE <br />OWNER ADDRESS 42649911:11r7TRUMHta 1636 g.K Cie 10 ),/ CITY/STATE/ZIP Ripon/CA/95366 <br />V&W Drilling Inc. CONTRACTOR <br /> <br /> PHONE 209-369-9600 <br />1133 Blackhurst Drive CONTRACTOR ADDRESS <br /> <br /> CITY/STATE/ZIP Galt/CA/95362 <br />Mid Pacific Engineering PHONE 916-516-2113 SUBCONTRACTOR/CONSULTANT <br />SUBCONTRACTOR/CONSULTANT ADDRESS 840 Embarcadero Drive, Suite 20 CITY/STATE/ZIP <br /> West Sacramento,CA, 95605 <br />LICENSE xJ C-57 0 C-61 C D-09 C Other NUMBER 720904 <br />EXPIRATION DATE 4/30/22 <br />BILUNG PARTY: D OWNER 0 CONTRACTOR D( SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: 0 General Mineral/Coliform Bacteria (4391) 0 Dibromochloropropane (4392) 0 Arsenic (4393) <br />INTENDED Us % 0 Domestic/Private G Irrigation/Agricultural 0 Industrial 0 Water Quality Monitoring Soil Sampling/Characterization <br />0 Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK C New Well 0 Replacement Well 0 Well Alteration/Modification 0 Other <br /> <br />g GeotechnIcal *of borings *of borings 0 Monitoring Well(s) # of wells 0 Soil Boring(s) <br />0 Out-Of-Service Well 0Out-Of-Service Well Renewal 0 Cross-Connection Repair <br />0 New Pump 0 Pump Replacement 0 Pump Repair 0 Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method yt Mud Rotary 0 Air Rotary IX Auger 0 Cable Tool 0 Push Point 0 Other <br />Proposed Well Depth 55 it Excavation 8 in diameter 0 Open Bottom 0 Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched 0 Steel 0 Plastic 0 Stainless Steel 0 Other <br />Grout Seal Depth 55 ft S Neat Cement (94 lb bag/5-10 gal water) 0 Sand Cement sack mix/7 gal water <br />0 Bentonite (20% solids) 0 Other <br />Grout Placement Method 0 Pumped 0 Free Fall R Other tremie U Retardant / Accelerator (name) <br />PEDESTAL Installed By C Driller 0 Pump Contractor 0 Other <br />0 Concrete Pedestal °Dimensions: Width It Length ft Thick In 0 Christy Box C Stove Pipe <br />IMP 0 Submersible 0 Turbine C 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 LJCENSE IS <br />CURRENT AND ACTIVE VVITHi THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION AWS. <br />MINI R A ANPB NQTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 93-769/ <br /> <br />TITLE fm DATE 1/Z0 ,2'l RTTO SIGNED <br />3ee' <br />444, <br />DEPARTMENT USE •NLY <br /> <br />Application Accepted By Date Area ilig9 Employee ID* 11-5 <br /> <br />Grout Inspection By Date 7:3 SPECIAL Well Permit <br /> <br />Pump Inspection By Date 7, WAIVER Received <br />Soil Boring Inspection Byc:-Dkn 9-- \ Date 2- t 13 t 1— \- Constructed Well Depth _ft <br />COMMENTS <br />PE <br />Codes <br />SC <br />Info <br />Is l) <br />Received <br />449...... <br />Checkii/ <br />e.C2,-. ex/- <br />Amount Dati Remitted <br />4-Lis-6 1 1114 ti <br />Permit/ <br />Aepqe RgstiesIfb, <br />Wyoui-ob% <br />Invoice # Well 105 <br />437 cl <br />1 1 1 <br />ENO 43-08 e1112019 WELL (PUMP PERMIT