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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 -REFUNDABLE PERMIT GALL (ZU9) 9OZ-fb9t FOR INSPECTIONS LAVIKICJ l TEAR FROM DATE ISSUED <br />JOB ADDRESS 333 East Main St CITY/ZIP Ripon, 95366 <br />CROSS STREET Frontage Rd APN 261-140-06 PARCEL SIZE 2.26 Acres LAND USE APPLICATION # <br />OWNER NAME Venture Hospitality, Inc. PHONE <br />OWNER ADDRESS 730 Motel Drive CITY/STATE/ZIP Merced, CA 93541 <br />CONTRACTOR Soils Engineering, Inc. PHONE (661) 831-5100 <br />CONTRACTOR ADDRESS 4400 Yeager Way CITY/STATE/ZIP Bakersfield, CA 93313 <br />SUBCONTRACTOR Middle Earth Geo Testing, Inc. PHONE (714) 633-5025 <br />SUBCONTRACTOR ADDRESS 134 S. Glassell St., Suite H CITY/STATE/ZIP Orange, CA 92866 <br />LICENSE [XC -57 ❑ C-61 ❑ D-09 ❑ Other NUMBER 253192 EXPIRATION DATE 08/31/2023 <br />DOMESTIC WELL SAMPLING: L General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) ❑ Arsenic (4393) <br />NTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring X Soil Sampling/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 ❑ Well Alteration/Modification ❑ Other <br />SC <br />Info <br />❑ Monitoring Well(s) # of wells ❑ Soil Borings) # of borings IX Geotechnical <br />7 # of borings <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />Is7o <br />❑ New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary ® Auger ❑ Cable Tool IN Push Point ❑ Other <br />Proposed Well Depth 50' CPT ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel <br />Size in diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter 8^ in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel <br />❑ Other <br />Grout Seal Depth 50' ft 9 Neat Cement (94 lb bag/5-10 gal water) ❑ Sand Cement <br />sack rnW7 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />P4YAM–her <br />Grout Placement Method ❑ Pumped ® Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />RECEIV= <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other MAY 05 <br />❑ Concrete Pedestal El Dimensions: Width ft Length ft Thick <br />�in ❑ Christy Box ❑ Stove Pipe SAN.,nAnt A, , <br />PUMP ❑ Submersible❑ Turbine ❑ Other HP Pump Set ft Standing WN FtRTmeror 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 lines, 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 />MINIMUM 24 HOUR ,ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />Application Accepted By L L— <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS F ewl,e 4a be rl W <br />DEPARTMENT USE ONLY <br />Date A, w <br />Date <br />Date <br />Date <br />Area S �� ''� Employee ID#'/ '✓ <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth ft <br />graoildwakr is entavnicrez /. <br />WI <br />m <br />D <br />0 <br />0 <br />m <br />PE <br />Codes <br />SC <br />Info <br />Received Check#/ <br />sh <br />Amount D to Permit/ Invoice # Well ID# <br />Remitted Service Request <br />y37a <br />Is7o <br />E 06 04/0 / 22 1Y <br />1 3 12-1 <br />2-f q 12, <br />5-111'- L ee I of 2 Wel I/ Pump Pennit <br />