Laserfiche WebLink
-D <br /> • WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)466-3420 <br /> NON-REFUNDABLE PER MJT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> fn <br /> JOB ADDRESS 12927 W. RIPON RD CITY/ZIP RIPON, 95366 m <br /> �J �� D <br /> CROSSSTREET JACKTONE RD APNZ / jjV-0 PARCEL SIZE LAND USE APPLICATION# G <br /> OWNER NAME CAROLL HEATWOLE l`.�i t�.`1 l-- �.� _�.'r1'.� HONE 456.1394 <br /> J <br /> LU <br /> OWNER ADDRESS 5629 ANDA CT. i�,-9C n�(„X l�76r' Y" CITY/STATE/GP jfI A'LIDA, CA. 95368 '344 C= =5 <br /> CONTRACTOR N&S IRRIGATION, INC PHONE 209.599.3456a .msa . s .�. W <br /> Cn <br /> CONTRACTOR ADDRESS 215 W. MAIN STREET CITY/STATE/ZIP RIPON e CA. 95366 � -=' <br /> SUBCONTRACTOR PHONE Z <br /> W <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C-57 C-61 D-09 XOther C10 NUMBER 662732 EXPIRATIONDATE 01/31/19 W <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br /> INTENDED USE XDomesticlPrivate i Irrigation/Agricultural Industrial i i Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner Water System Name ontact ame or one um er <br /> TYPE OF WORK New Well Replacement Well i Well Alteration/Modification i Other <br /> Monitoring Wells) #of wells Soil Boring(s) #of borings Geotechnical #of bo ings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement i i Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Well Depth 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_in Thickness/Gauge/ASTM Schad Steel Plastic Stainless Steel Other <br /> Grout Seal Depth ft Neat Cement(94 Ib bag15-10 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 XSubmersiblei Turbine 1 Other HP__3_ Pump Set ft Standing Water Level It <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> J UIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURR ANDA E WITH THE CALIFORNIA C TRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMP S TION L W ./ <br /> I M M 4 0 R D N OTICE REQUIRED FOR INSPECTIONS--PLEASE CALL(209)953-7697 <br /> $I ED TITLE /v 1'I I "'�'C=JC�/L_ DATE 7 3✓,'l 7 <br /> N <br /> E <br /> S <br /> PAYMENT <br /> RECEIVED <br /> AUG 0 4 2011 V— <br /> SAN . ,�r)ufH cou <br /> Eh-�• 'ni�_NTAL <br /> •+EALTti JL-nRT-MEN <br /> B>EP R T M E N T,4 E I N L Y �j/�� <br /> Application Accepted By Date \ Area Employee ID# ie: <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date � — WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Chec Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Remitted Service Re uest# <br /> C)50 <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4/30/12 <br />