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WELL/PUMP PERMIT <br />SAN JOA(XAN COUNTY ENVIRONMENTAL HEALTH DEPAMENT 1868 EA3T HAWLTON AVENUE - Sr*=T*mCo k 95205 - 1209) 4611,3420 <br />NON-REFUNDABLE PERMIT CALL 1209) 953-7697 FOR INSPECTIONS EXF4RES I YEJ R FROM DATE ISSUED <br />!ice Ac s3 22844 S. FREDERICK AVE. crrvrzw RIPOM 9!366 <br />icRms-mEET, W. RIPON RD. APN 2,Z'Q 2_; P. s. Use Ammwr cm <br />I <br />iOwwR N"f DALE KUIL Pwwa 209.5{F9.4960 <br />ow,*R Aamess 22844 S. FREDERICK AVE. cmyr.TA-mop RIPON, CA. S 5366 <br />CONTRACTOR NA 1,; 'RR1C,'ATj0Nr, !AlC — PH**w 2TA 54_m,1% <br />CO --A— 915W MAINSIRE ET CITY"SIA-z- IRON CA gr366 <br />SUWAWMAL-tok PHONE <br />,3USCUN1Y2Ac,roR Aamss Cn`YMTATE1W_ <br />UcEme C-57 C-61 0-09 NuwmK_QU132_ ExmUT1*N0*Tx__QjL1�__ <br />— T_" — Range Sec <br />tion— <br />onlionng -,,Soo <br />C*Auul r0m w I <br />TYK Of WOFK New well Replace rnenlNick Well Aftorabor*1oftcat" Odher <br />M-9 vve!a� III of Web Sod Bonngis) eottwnnpr Geolachniew <br />Oul OI Out Of Ser a Ce w" Renewal Ctoaal,otu n Repair <br />New PmX PtiftR P R Rw" we# Cuft <br />WELL CoNaTRUCTION <br />Drilling Method Mud Rotary Auger C81:98 Toof Push Point oil -- <br />Proposed Well Depth ft Excavation — in diagnater I Open Bottom Gravel PaduGra%rel St a in diameter <br />Conductor Casing _ m dmmw ' Conductor Casing Depth It <br />Well Casing Diameter,„ in ThicimssiGattgaiASTM S&wd _ , Steel Plastic Stainless Stow Other, <br />Grout Seat Depth _ft ,, N" Cement (94 ]b bagl5-10 gal water) sand Cern em_ —sack nwa gm waw <br />Barflonite (20% wWs) L; Other <br />Grout Ptacernent Method Pumped ': Free Fall , Other Ratmiant I AcceieraW (nam) <br />PEMSTAL Installed By Driller ,, Pump Contractor Other <br />onCrete Pedestal Dkntnaldwrs: Width _ It L&qo _ It Thia _ in Christy . it Stova p4w <br />p ,figX6'uWr*es4b1t TtM*m Other _ HP Pump set It Standing W4 W Level It <br />I HEREBYER = THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACC 30DANCE WITH SAN <br />JOAQUIN 1,0,1PANNANCES, STATE LAWS. AND RULES AND REGULATIONS. I ALSO CERTIFY THAI' my RiquIRIED LICENSE is <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />EPARTMENT USE QNLY <br />Apphuition Accepted 13 .. I I 4= . 7h 7, J I Y E mployee oal,9_5 <br />Pump I n svp e -WAV -n By 7�� Date WAIVER Rea lived <br />Soil Boring In By <br />By <br />COMWNTS <br />All - <br />F+0 4346 <br />4W12 <br />Datt <br />Constructed Well Depth <br />