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\ J <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)4683420 <br /> NON-REFUNDABLE PERMIT <br /> www.sjgov.orgtehd `EXPIIRESI YEAR FROM DATE <br /> ISSUED <br /> JOB ADDRESS /aj,A :^ CITY21P r�6ci"0'VV Yf�/V <br /> f.G� c�.S�aOQ f <br /> CROSS STREET �(�P� APN ARCEL SIZE��f LAND USE APPLICATION aK1�t'f C'U1Oo <br /> m <br /> OWNER NAME Brazil&Van Rvn DairY LLC PHONE (209)482-2295 <br /> OWNER ADDRESS P.O.Box 149 CITY/STATEZP Ripon,CA 95366 <br /> CONTRACTOR Nor-Cal Pump&Well Drillina.Inc. PHONE (530)674-5661 <br /> CONTRACTOR ADDRESS 1325 Barry Road CITY/STATEMP Yuba City,CA 95993 <br /> SUBCONTRACTORICONSULTANT n/a PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATERIP <br /> LICENSE XC-57 XC-61 XD-09 Other NUMBER 908591 ExPIRAnoN DATE 01/31/20 <br /> BILLING PARTY: XOWNER CONTRACTOR SUBCONTRACTOWCONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392)- Arsenic(4393) <br /> INTENDED USE Domestic/Pfivate X Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If different hom Ownar. Wale,System Name Conlact Neme or Phone Number <br /> TYPE OF WORK XNew Well Replacement Well Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells Soil Boring(s) a of bo""es Geotechnical •or bonngs <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> XNew Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method X Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Well Depth 450' R Excavation 28 In diameter Open Bottom x Gravel Pack/Gravel Size TBD in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth f1 <br /> Well Casing Diamete�r�/In�{/�(Thickness/Gauge/ASTM Sched .250 x Steel Plastic _ Stainless Steel Other <br /> Grout Seal Depth Diameter <br /> +eft Neat Cement(94/b bag,5-10 gal water) Sand Cement sack mixll gal water <br /> Benlonite(20%solids) x Other 10.3 sack <br /> Grout Placement Method x Pumped Free Fall _ Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By _ Driller x Pump Contractor Other <br /> x Concrete Pedestal Dimensions:Width 5 ft Length 5 H Thick 5 in Christy Box " Stove Pip* <br /> PUMP Submersible x Turbine Other HP 75 HP Pump Set TBD fl Standing Water Level unkown ft <br /> I HEREBY CERTIFY THAT 1 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 /> CURRENTAND TIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COM SATION LAWS. <br /> MINIM B HOU DVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE Nar Hear,President/CEO DATE 12116/19 <br /> -PkVMENT <br /> �y <br /> EIVED <br /> 7 0, 2019 <br /> ' QUIN COUNTY <br /> V RONMENTAL <br /> TA DEPARTMENT <br /> P TMENT VSE�nNN LY <br /> 1111 MAqq <br /> Application Accepted By ate ZI' r• ' Area Employee ID#*Ae��M <br /> Grout Inspection By n Date SPECIAL Well Permit <br /> Pump Inspection By Date �..ice`-�-�'` 1(=;1._.� WAIVER Received <br /> Soil Boring Inspection <br /> �Bfy� c Dale Constructed Well De <br /> COMMENTED <br /> PE SC Raiceivelf Whec Amount is Pill Invoice# Well ID# <br /> Codes Info Cash emitted Service est# <br /> o A <br /> o tW?00404 <br /> EHD43-M 611141019 WELL!PUMP PERMIT <br />