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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 />NON-KEFUNDABLE PERMIT L:ALL (ZUUj y53 -/by/ FOR INSPECTIONS IZAPIKtJ 7 YEAR FROM LJATE ISSUED <br />JOB ADDRESS 17023 E. MILGEO AVE �, ^r CITY/ZIP RIPON, 95366 <br />CROSS STREET MURPHY RD APN-{ S���o / 0 ]—PARCEL SIZE) LAND USE APPLICATION# <br />OWNER NAME BRUQFz RANKIN PHONE 599.3993 <br />OWNER ADDRESS 170 E. MILGEO AVE CITY/STATE/ZIP RIPON, CA. 95336 <br />CONTRACTOR N & S IRRIGATION, INC PHONE 209.599.3456 <br />CONTRACTORADDRESS 215 W. MAIN STREET CITY/STATE/ZIP RIPON, CA, 95366 <br />SUBCONTRACTOR 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 Y Township_ Range Section <br />NTENDED USE , Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System <br />If different from Owner: Water System Name on a ame or Phone Number <br />TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br />Monitoring Well(s) # of wells Soil Boring(s) _ # of borings Geotechnical # of borings <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br />Proposed Well Depth It Excavation in diameter 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 Plastic Stainless Steel Other <br />Grout Seal Depth ft Neat Cement (94 lb bagl5-10 gal water) Sand Cement sack mixf7 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 HIP �_ Pump Set It Standing Water Level ft <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRE T AND AC 1C(E WITH THE ALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />ORKE COMPE SATION L S. <br />MINI 4 OU A VA C CE REQUIRED FO I /TIONS - PLEASE CALL (209) 953-76697 <br />SIGNE TITLEPPEC'' DATE –7 <br />PAS b <br />RECEIVE <br />w <br />N <br />D <br />0 <br />0 <br />m <br />ut <br />PTED <br />''' IL 7 2017 <br />IL HEALTH <br />VICES <br />SENVAR N)MEN4� I I° 1 1 1 1 1 1 <br />9EALTH DEPARTMENT <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />TMENT USE ONLY <br />_Date Area Employee ID#�U <br />Date SPECIAL Well Permit <br />Date WAIVER Received <br />Date Constructed Well Depth ft <br />PE SC <br />Codes Info <br />Received a #/ <br />B s <br />Amount Date <br />Remitted <br />PermiU <br />Service Re uest # <br />Invoice # Well ID# <br />0 <br />�Ga3 9 <br />``11 INIl <br />0031(P38 <br />EHD 43-06 WELL /PUMP PERMIT <br />4/30/12 <br />