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I WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN-KEFUNDABLE PERMIT GALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 22640 South Murphy CVL 01839 clrr/zIP Ripon/95366 <br />CROSS STREET E Milgeo Ave APN 245-190-45 PARCEL SIZE 28.74 Acre LAND USE APPLICATION # <br />OWNER NAME Kamps Colony Road. Prop li LP PHONE <br />OWNER ADDRESS 22640 South Murphy Road #8 CRY/STATE/ZIP Ripon/CA/95366 <br />CONTRACTOR V & W <br />CONTRACTOR ADDRESS 1133 Blackhurst Drive <br />SUBCONTRACTOR Mid Pacific Engineering <br />PHONE 209-369-9600 <br />CnY/STATE/LP Galt/CA/95632 <br />PHONE 916-516-2116 <br />SUBCONTRACTOR ADDRESS 840 Embarcadero Drive, Suite 20 CITY/STATE/Zip-West Sacramento/CA/95605 <br />LICENSE 91 C-57 7 C-61 D-09 i Other NUMBER 720904 EXPIRATION DATE 04/30/2022 <br />DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (439 1) ❑ Dibromochloropropane (4392) ❑ Arsenic (4393) <br />INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring d Soil Sam piing/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 I Well Alteration/Modification U Other <br />Monitoring Well(s) # of wells i Soil Boring(s) # of borings yGeotechnical 1 # of borings <br />Out -Of -Service Well Out -Of -Service Well Renewal i i Cross -Connection Repair <br />New PumD PumD ReDlacement PumD Repair Raise Well Casino <br />Drilling Method %! Mud Rotary I Air Rotary yr Auger Cable Tool . Push Point Other <br />Proposed Well Depth 50 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 i Plastic Stainless Steel L Other <br />Grout Seal Depth 50 ft V Neat Cement (94 Ib bag(5-10 gal water) Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) I Other <br />Grout Placement Method Pumped yr Free Fall V Other Tremie Retardant / Accelerator (name) _ <br />PEDESTAL Installed By i Driller Pump Contractor i Other <br />Concrete Pedestal Dimensions: Width ft Length ft Thick <br />in Christy Box Stove Pioe <br />PUMP _ Submersible. Turbine Other HP Pump Set ft Standi*Me&dvel"--" ft <br />Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect to the fo 18wNX; 4t*V GPS <br />Coordinates, property lines, adjoining properties, water bodies or courses, drainage pattern, roadsp dWigui�ures, <br />potential sources of contamination, sewers or private disposal systems. Include distance from two pro 40psalitNestic, <br />Agriculture, Industrial well, provide location of any water wells or surface water within 200' radius of proposed well. <br />\I1\1\11 \124114H R \11% \\( IF, \(lli( I I'F)'-( Ik1':I)1- )k l 110,1 P1 j. %',1 i \ A i209ti Y--, '0 - <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS IT e -J 99 <br />DEPARTMENT USE ONLY <br />Date 07)7 <br />4 d <br />Date <br />Date <br />Area S C Employee ID# <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Date (O—"l —Z1- Constructed Well Depth <br />ft <br />T <br />PE SC Received Check#/ Amount Permit! <br />Codes Info B Cash Remitted Dae Service Request # <br />Invoice # Well ID# <br />I5 'l <br />F,HD041-06 IW2512021 4,,41 —* 13-9 ]„���pag � - /h / 2 2— WCII' Pump Pcrmit <br />