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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />IYVIY-Ktt-UNUACLt rtKMI I 1..ALL LU11UOI-IOU[ FUR INSYtG IIUNS rArlKtJ l TEAR FROM DATE ISSUED <br />JOB ADDRESS <br />22161 S OLIVE AVE <br />CITY/ZIP RIPON, 95366 <br />CROSS STREET <br />W. RIPON RD <br />/� <br />APN 2 � - /�d - O3 PARCEL SIZE LAND USE APPLICATION # <br />OWNER NAME <br />BRYCE PERKINS <br />O)fI,rc iG PHONE 495.2089 <br />OWNER ADDRESS <br />22161 S. OLIVE AVE <br />CITY/STATE/ZIP RIPON, CA. 95366 <br />CONTRACTOR <br />N & S IRRIGATION, <br />INC PHONE 209.599.3456 <br />CONTRACTOR ADDRESS 215 W. MAIN STREET <br />CITY/STATE/ZIP RIPON CA- 95366 <br />SUBCONTRACTOR <br />PHONE <br />SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br />LICENSE C-57 C-61 D-09 XOther C10 NUMBER 662732 ExPIRATION DATE 01/31/19 <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township _ Range Section <br />NTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System <br />If dixerenl from Owner: Water bystem Name on a ame or Pnone Numner <br />TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br />Monitoring Well(s) _ # of wells Soil Boring(s) # of borings Geotechnical # or borings <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />New rump IN <br />"dlse vveu <br />Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br />Proposed Well Depth ft Excavation in diameter 1 Open Bottom Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched Steel i Plastic Stainless Steel Other <br />Grout Seal Depth ft Neat Cement (94 Ib bag/5-10 gal water) i Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method Pumped Free Fall Other Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor Other <br />Concrete Pedestal Dimensions: Width ft Length ft Thick in Christy Box Stove Pipe <br />PUMP XSubmersible Turbine Other HP 2 Pump Set 60 It Standing Water Level 24 ft <br />I HEREBY CERTIFY THAT I 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 />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />RECE yE <br />auG � 1 <br />SAN YDAn NM <br />EN�aDDER, <br />H�TM <br />E REQUIRED FOR INSPECTIONS -- PLEASE CALL (209) 953-77697 <br />TITLE Mft DATE g I 1 <br />u <br />ti <br />F -P RTMENT SE ONLY <br />Application Accepted By DateAtIArea Employee ID� <br />Grout Inspection By Date If P L Well Permit <br />Pump Inspection By a Date -. WAIVER RBCBIVed <br />Soil Boring Inspection By 4b` DateConstru ed Well Depth ft <br />COMMENTS SCS /vc%t Ii f. <br />PE SC Received Check Amount Date Permit/ Invoice# WellID# <br />Codes Info lily, ash Remitted Service Re uest # <br />n wib 2Z 00370.7 <br />EHD 43-06 <br />4/30/12 <br />WELL /PUMP PERMIT <br />