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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />NON-REFUNDABLE PERMIT www.sjgov.org/ehcl tA1`IKtJ "I T EAK I-KUM UA It Ibbutu <br />JOB ADDRESS 142 S Industrial Ave �3 r CITY/ZIP Ripon / 95366 <br />CROSS STREET Main Street APN 7 3 9 0 PARCEL SIZE _� _LAND USE APPLICATION # NIA <br />OWNER NAME City of Ripon PHONE (209) 599-0233 <br />OWNER ADDRESS 259 N. Wilma Avenue CITY/STATE/ZIP Ripon/CA/95366 <br />CONTRACTOR <br />Crawford & Associates, Inc. <br />CONTRACTOR ADDRESS 1100 Corporate Way Suite 230 <br />SUBCONTRACTOR/CONSULTANT Geo -Ex Subsurface Exploration <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />LICENSE ,IC -57 C-61 <br />BILLING PARTY: OWNER <br />704 North Adams Street <br />D-09 Other <br />CONTRACTOR <br />CITY/STATE/ZIP <br />CITY/STATE/ZIP_ <br />NUMBER 954267 <br />SUBCONTRACTOR/CONSULTANT <br />PHONE (916)455-4225 <br />Sacramento, CA, 95831 <br />PHONE (916)799-8198 <br />Dixon / CA / 95620 <br />EXPIRATION DATE 7/31/2022 <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />NTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring VSoil Sampling/Characterization <br />Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK <br />New Well Replacement Well Well Alteration/NJc>dification Other <br />Monitoring Well(s) # of wellsoil Borings # of borings /Geotechnical <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />New Pump Pump Replacement FNump Kepair t<alse vveu <br />WELL CONSTRUCTION <br />Drilling Method /Mud Rotary Air Rotary //Auger Cable Tool Push Point <br />Proposed Well Depth 5-80 ft Excavation 4-8„ in diameter Open Bottom <br />Conductor Casing in diameter / Conductor Casing Depth <br />Other <br />3 # of borings <br />Gravel Pack/Gravel Size <br />ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel <br />Grout Seal Depth full depth ft /Neat Cement (94 lb bag/5-10 gal water) Sand Cement <br />Bentonite (20% solids) Other <br />Grout Placement Method /Pumped /Free Fall Other Retardant / Accelerator (name) <br />in diameter <br />Other <br />sack mix/7 gal water <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 />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 />F <br />MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />DEPARTMENT USE ONLY <br />Application Accepted By ji 1i Date P/034 <br />Grout Inspection By Date <br />Pump Inspection By Date <br />Soil Boring Inspection By Date <br />COMMENTS <br />Area—rI� UYI Employee ID# A <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth ft <br />PE <br />Codes <br />Sc Received Check#/ <br />Info Bv Cash <br />Amount DatePermit/ <br />Remitted <br />Invoice # Well ID# <br />Se ice Request # <br />�a <br />ts0 <br />7 <br />�� <br />EHD 43-06 6/11/2019 /y W Ty /��//���i /� WELL /PUMP PERMIT <br />