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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 /> JOB ADDRESS 12674 E. West Ripon Rd. CITY/ZIP Ripon 95366 <br /> i <br /> CROSS STREET W. of S. Mohler Rd. APN 25727043 1 0 <br /> PARCEL SIZE LAND USE APPLICATION# p <br /> OWNER NAME John Cover PHONE 209-985-4085 m <br /> 12674 E. West Ripon Rd. Ripon, CA 95366 <br /> OWNER ADDRESS CITY/STATE/ZIP p <br /> CONTRACTOR Hennings Bros. Drilling Co., Inc. <br /> PHONE 209-545-1185 <br /> CONTRACTOR ADDRESS 1930 Ladd Rd. CITY/STATE/ZIP Modesto, CA 95356 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE EXC-57 ❑ C-61 ❑ D-09 Ll Other NUMBER 290813 EXPIRATION DATE May 31, 2028 <br /> DOMESTIC WELL SAMPLING:x General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic(4393) <br /> INTENDED USE iXDomestic/Private ❑ Irrigation/Agricultural 7 Industrial LJ Water Quality Monitoring I! Soil Sampling/Characterization <br /> D Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ❑ New Well FXReplacement Well I Well Alteration/Modification ❑ Other <br /> J Monitoring Well(s) #of wells I..I Soil Borin s #of borings f borings <br /> O <br /> 9O J Geotechnical---�/#o s� g <br /> a Out-Of-Service Well CI Out-Of-Service Well Renewal f: Cross-Connection Repair v <br /> Li New Pump ❑ Pump Replacement Li Pump Repair C;WELL CONSTRUCTION Raise Well Casino `SA1y 2026 <br /> Drilling Method [XMud Rotary ❑ Air Rotary ❑ Auger Ii Cable Tool LI Push Point L. Other H�NT ROHMECOVNr. <br /> Proposed Well Depth 200' ft Excavation 12 in diameter ,I Open Bottom XGravel Pack/Gravel Size n0 iA�iame er <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter 6 in Thickness/Gauge/ASTM Sched SDR 21 I Steel X Plastic i Stainless Steel Other <br /> Grout Seal Depth 100 ft D Neat Cement(94 lb bag/5-10 gal water) i' Sand Cement sack mix/7 gal water <br /> i)(Bentonite(20%solids) ❑ Other <br /> Grout Placement Method CXPumped ❑ Free Fall 11 Other I I Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller I-XPump Contractor ❑ Other <br /> 1 Concrete Pedestal❑Dimensions:Width ft Length ft Thick <br /> in ❑ Christy Box ❑ Stove Pipe <br /> PUMP ❑ Submersible❑ Turbine U 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 /> DEPARTMENT USE ONLY <br /> Application Accepted By J�/aSKi� Date 7 t7 Z Area 41 Employee ID# <br /> Grout Inspection By Date PZ SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS 'LD %Oat!;t.S f A:5(VI <br /> PE SC Received Amount Permit/ <br /> Codes Info Cash Remitted Date Service Request# Invoice# Well ID# <br /> + z-1 26 \NP260196 <br /> two <br /> EHD043-06 04107i2022 <br /> Page Iol'2 oa a in o ccela wo,/Pum,Pcmut <br />