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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENNRONMENTAL HEALTH DEPARTMENT I a&8 EAST HAZELTON AVENUE - STOCKTON CO 95205 - (209) 468.3420 <br />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />rn <br />JOB ADDRESS 22844 FREDERICK RD CITYMP RIPON 95366 � <br />.y ga <br />CROSS gTR� W. RIPON APIN i,y t L p' PARCEL SIZE is L LAND USE APPUCA n:)N A� m <br />OWNER NAME DALE KIJIL PHONE 209-610-5829 <br />OWNER ADDRESS 22844 FREDERICK RD CITY/STATE/ZIP RIPON CA 95366 <br />CONTRACTOR N & S IRRIGATION INC PHONE 209.59:).3456 <br />CONTRACTOR ADDRESS 2-1.5..W MAIN STREET Crry/STATEizp RIPON, CA. 9E366 _ <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS r'+ CITY/STATE/7JP <br />LICENSE C-57 C-61 D-09 }Other C10 NUMBER &62732 EXPIRATION DATE_ 0/15 <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township_,,,, Range _____ Section <br />INTENOEo USE Domestic/Pnvate - Imgabon/Agricutturai Industrial Water Quality Monitoring Soil Sampling/Ch aractenzation <br />Public Water System <br />It tutternrn from owner: or SVSI— — � N—tee <br />TYPE OF WORK New Well :. Replacement Well Weil AlterationlMddificaton Other <br />Monitoring Well($) #of wells SoilBonng(s) #.Iwnrpa _- Geotechntcal__Oofwo (;g <br />,,,,... :" R Out -Of -Service Well Penaw2l Cross -Connection Repair <br />New Pumo X Puma Reolacament _ Pumo Repair Raise Well Casing____ <br />Drilling Method Mud Rotary Air Rotary I Auger Cable Tool I Push Point Otner <br />Proposed Woli Depth ft Excavation in diameter Open Bottom Gravel Pack/Gravel Si to to diameter <br />Conductor Casing in diameter I Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched I Steel . Plastic . Stainless Steel Other <br />Grout Seat Depth ft Neat Cement (94 Ib bag/5 TO get water) Sano Cement sack mrx17 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method Pumped Free Fall I Other Retardant / Acceierator (name) <br />SPE TA Installed By - Driller _. Pump Contractor Other <br />Concrete Pedestal D mens ons: Width tt Length ft Thick in Christy Box Stove Pipe <br />!pump .. Submersible - Turbine - Other HP 112 Pump Set _ 41 ft Standing Water Level --3 - It , <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 F:EQUIRED LICENSE IS <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br />WORKERS COMPEN3ATiON LAWS. <br />PA.'YME <br />REC1;-S\ <br />QCi 2 <br />SAN JOAQUI <br />gw1VIRON'' <br />-+eAt Tt1 CIE' <br />24HO RADy10EREWj9EDF0 PECTIONS - PLEASE CALL (2119) 953-7697 <br />/`-✓r>,.+r a- DATE <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspettitmay <br />Soil Boring <br />COMMENTS__ <br />DEPARTMENT USE ONLY <br />-. Date <br />✓'/� Date <br />Date <br />VEIt I <br />2015 <br />kL HEALTH <br />H <br />IVICES <br />4 <br />Area_&_LEmployee ID4'`7 °v <br />ECTAL W< II Permit <br />WAIVER Ret;eived <br />�str aq Weil Qeptt _tt <br />'s "I'll� <br />PE I SC Received <br />Codes Info B <br />het Amount Date <br />Remkied <br />Permit' Invoice p Well 1D# <br />Service Request 0 <br />y <br />I <br />I <br />f.H0 43 Je <br />4W11 <br />