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WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205_ -6232 (209)468-3420 NON-REFUNDABLE PERMIT www.sj•aov.oro/ehd EXPIRES 'I YEAR FROM DATE ISSUED ,Joe ADDRESS 22898 North Ripon Road _ cITY/zIP Ripon, CA 95366 ' ! i _ imm CRbSSSTREET E Boesch Drive _ APN 26121oo8 PARCELSIZE 12-43 LAND USE APPLICATION# _- o OWNER NAME HPG Ripon Development LLC ___• PHONE-935--3j-4---9040 OWNER ADDRESS PO BOX 1096 _ _ CITY/STATE/ZIP i?anVIIIe,SA ��26 CONTRACTOR Middle Earth Geo Testing PHONE635025 CONTRACTOR ADDRESS 954 N Lemon Street CITY/STATE/ZIP Orange, CA 92867 SUBCONTRACTOR/CONSULTANT Mid Pacific Engineering, Inc. 916-662-0909 4b --4 b�,.. PHONE SUBCONTRACTOR/CONSULTANT ADDRESS 840 Embarcadero Drive, Suite 20 CITY/STATE/ZIP W. Sacramento Ca 95_ft LICENSE X C-57 C C-61 C D-09 C Other NUMBER 899451 EXPIRATION DATE O 2OYI.A3 BILLING PARTY: D OWNER ❑CONTRACTOR SUBCONTRACTOR/CONSULTANT DOMESTIC WELL SAMPLING:C General Mineral/Coliform Bacteria(4391)7 Dibromochloropropane(4392)C Arsenic(4393) INTENDED,USE 0 Domestic/Private C Irrigation/Agricultural D Industrial 0 Water Quality Monitoring X Soil Sampling/Characterization ❑ Public Water System__._ If different from O•veer: Water System Name Contact Name or Phone Number TYPE OF WORK C New Well 0 Replacement Well ❑ Well Alteration/Modification 0 Other ❑ Monitoring Wells) #of wells ❑ Soil Boring(s) *of borings of borings Cl Geotechnical�— 0 Out-Of-Service Well C Out-Of-Service Well Renewal ❑ Cross-Connection Repair 0 New Purno 0 Pumf:Re ilacement 0 Pumf;Re�)air _ ❑ Raise Well Casirn WELL CONSTRUCTION Drilling Method Cl Mud Rotary 0 Air Rotary 0 Auger ❑ Cable Tool (Push Point ❑ Other .Proposed Well Depth SO It Excavation --'2 in diameter 0 Open Bottom 0 Gravel Pack/Gravel Size—- in diameter] C Conductor Casing in diameter I Conductor Casing Depth ft Well Casing Diameter_ in Thickness/Gauge/ASTM Sched D Steel 0 Plastic C Stainless Steel 0 Other Grout Seal Depth SO ft Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement--.—.--..- _ sack mix/7 gal water 0 Bentonite(20%solids) 7 Other _ Grout Placement Method A Pumped 0 Free Fall Other —' -- ❑ Retardant/Accelerator(name) - - PEDESTAL Installed By C Driller 0 Pump Contractor 0 Other 0 Concrete Pedestal❑Dimensions:Width ft length ft Thick _ in 0 Christy Box CStove Pipe --. — _ — IPuMP_ 31 Submersible❑ Turbine 2 Other _HP Pump Set_ _ft Standing Water Level ft I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTRDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND CT E WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMNS TION LAWS. MINIMI HOUR AD CE NOTICE REQUIRED F INSPECTIONS - PLEASE CALL (2019)) 3-7 95SIGNED TITLE It tS'• /•I.6Ln0-cRiles DATE `C/3 �97 2 b 7 Ll . i I l I I I i i I IAA - DEPARTMENT USE ONLY Application Accepted By Date 7 c/ a Area I Employee ID# v Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS PE SC Received Check#/ Amount Permit/ Codes Info B Date Cash Remitted Service Re uest# Invoice# Well ID# y37-2 so 7&-D Z 2 EHD 43-06 El11/2019 WELL/PUMP PERMIT