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1 ` WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> I go <br /> JOB ADDRESS 23861 S. Austin Rd. CITv/ZIP Ripon 95366 M <br /> m <br /> D <br /> CROSS STREET N. of W. Ripon Rd. APN 226-15-026 PARCEL SIZE 2.00 LAND USE APPLICATION# <br /> m <br /> OWNER NAME Bob Snodgrass PHONE 209-404-8535 <br /> OWNER ADDRESS 23861 S. Austin Rd. CITY/STATE/ZIP Ripon, CA 95366 <br /> CONTRACTOR Hennings Bros. Drilling Co.. Inc. PHONE 209-545-1185 <br /> CONTRACTOR ADDRESS 1930 Ladd Rd. CITY/STATEIZIP Modesto, CA 95356 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE . C-57 C-61 D-09 I Other NUMBER 290813 EXPIRATION DATE May 31, 2022 <br /> DOMESTIC WELL SAMPLING:. ,General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic(4393) <br /> INTENDED USE ] Domestic/Private - Irrigation/Agricultural ❑ Industrial CI Water Quality Monitoring ri Soil Sampling/Characterization <br /> i Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well X Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings I Geotechnical #of borings <br /> Out-Of-Service Well ❑ Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement ❑ Pump Repair L Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method C(Mud Rotary Air Rotary Auger Cable Tool _ Push Point I Other <br /> Proposed Well Depth 250 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 6 in ThicknesslGauge/ASTM Sched SDR21 Ei Steel Plastic ; Stainless Steel I:; Other <br /> Grout Seal Depth 200 ft ❑ Neat Cement(94 Ib bag/5-10 gal water) Sand Cement sack mix17 gal water <br /> X Bentonite(20%solids) ❑ Other <br /> Grout Placement Method X Pumped 17 Free Fall 17 Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller X Pump Contractor Other <br /> ❑ Concrete Pedestal ❑Dimensions:Width ft Length ft Thick <br /> in ❑ Christy Box ❑ Stove Pipe <br /> (PUMP ❑ Submersible❑ Turbine Other HP Pump Set ft Standing Water Level 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 /> NIINI,MUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Area lei0/ Employee ID# AG <br /> Grout Inspection By 1 f \ Date Z SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS �.risflnri J4 P. 11 {v FIMS.t:� Wf!!LPvIL' ��ca4tlJ>1 vie(1 CfL dV d <br /> ,92r11 A <br /> J <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# <br /> AWN MEEIN-10- <br /> Codes Info B Cash Remitted Service Rgguest# <br /> `13"i3 1 3az 00 LAS <br /> IN COUNrf <br /> EIMRO MENTAL <br /> tHU TH DEPARTMENT <br /> E10043-0610/2512021 Page 1 oft Well/Pump Permit <br />