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1 WELUPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN-KEFUNDABLE t'ERMIT GALL (ZUV) V03-/0ti/ FOR 1N5PEGTIUN5 CArIMr-0 I TtAK FKUM LlAIt IJJUEU <br />JOB ADDRESS 301 NORTH ACACIA AVENUE CITY/ZIP RIPON, 95366 <br />CROSS STREET PINE STREET APN 2590401 d PARCEL SIZE 18.5 acres LAND USE APPLICATION # <br />OWNER NAME RIPON UNIFIED SCI COOL DISTRICT PHONE <br />OWNER ADDRESS <br />364 NORTH ACACIA AVENUE <br />CITYISTATE/ZIP <br />RIPON, 95366 <br />CONTRACTOR <br />HALEY & ALDRICH, INC <br />PHONE 510-879-4579 <br />CONTRACTOR ADDRESS 426 17th STREET <br />CITY/STATEfZIP <br />OAKLAND/CA/94612 <br />SUBCONTRACTOR <br />PITCHER SERVICES, LLC <br />PHONE (650)32B-8910 <br />SUBCONTRACTOR <br />ADDRESS 218 DEMETER STREET <br />CITYISTATEIZIP East Palo Alto/CA/94303 <br />LICENSE C-57 C-61 D-09 Other <br />NUMBER 1041k84S <br />EXPIRATION DATE '9 �Sa I LyZZ <br />DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) ❑ Arsenic (4393) <br />INTENDED USE C Domestic/Private D Irrigation/Agricultural C Industrial C Water Quality Monitoring a Soil Sampling/Characterization <br />Public Water System <br />It different from owner.. Water System Name Contact Name or Plane Number <br />TYPE OF WORK 0 New Well G Replacement Well ❑ Well AlteratiordMDdification i Other <br />C Monitoring Well(s) # of wells D Soil Boring(s) a of borings X Geotechnical 5 0 of borings <br />�1 Out -Of -Service Well D Out -Of -Service Well Renewal !7 Cross -Connection Repair <br />-- New Pump Pump Replacement 0 Pump Repair Raise Well Casing AA <br />WELL CONSTRUCTION RE �► mE� y <br />I Drilling Method F. Mud Rotary ❑ Air Rotary +a Auger C Cable Tool a Push Point f, Other v <br />Proposed Well Depth_ 60 ft Excavation in diameter 7 Open Bottom C Gravel Pack/Gravel Size in r1Z <br />Conductor Casing in diameter / Conductor Casing Depth ft C 0 202' <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched 0 Steel C Plastic [1 Stainless Steel "k,wi <br />Grout Seal Depth 60 ft N Neat Cement (94 Ib bag/5-10 gal water) C Sand Cement-90"ter <br />Bentonite (20% solids) ❑ Other iffIyMF <br />!Grout Placement Method A Pumped C Free Fall 'IOther 0 Retardant / Accelerator (name) 7116 <br />PEDESTAL Installed By LI Driller _ Pump Contractor ❑ Other <br />Concrete Pedestal 7Dimensions: Width ft Length ft Thick <br />In _ Christy Box I Stove Pipe <br />PUMP 7 Submersible-- Turbine C Other I HP Pump Set ft Standing Water Level ft <br />Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect to the following items: GPS <br />Coordinates, property tines, adjoining properties, water bodies or courses, drainage pattern, roads, existing wells, structures, <br />potential sources of contamination, sewers or private disposal systems. Include distance from two property lines. For Domestic, <br />Agriculture, Industrial well, provide location of any water wells or surface water within 200' radius of proposed well. <br />\ 11 '\ 1 X11 %124 11OL R ADVA\CE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CAL -I. (209)953-7697 <br />DEPARTMENT USE ONLY <br />Application Accepted By L Z— Date Z '1 <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />Date <br />Date <br />Area-�/ Y1 Employee ID# <br />D SPECIAL Well Permit <br />❑ WAIVER Received <br />Date I Z D Constructed Well Depth <br />ft <br />?i <br />EHA043-06'O4512-021 Page] ot'- Well / Pump Permu <br />