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WELLIPUMP PERMIT <br /> SAN JOAOt11N COUNTY ENVIRONMENTAL HEAL'rn DEPARTMENT 1368 EAST HALEL-,"AVENUE-STOCKT JN CA 95205-(209)4£&-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Jos ADDRESS 24320 S FREDERICK RD. RIPON. 95066 <br /> c, <br /> (CROSS STREET W. RIPON RD. APNZ / PARCEL SIZE�LAN'D USE APF LICATION# m <br /> a <br /> OWNER NAME COLLEEN GORGAS PHONE 5993,9133 <br /> OWNER ADDRESS 24320 S FREDERICK RD, CITYIsrATE1LP RIPON,CA 95366 I <br /> CONTRACTOR N t&S IRRIGATION INC PHONE 209.599.3456 <br /> CONTRACTOR ADDRESS 215 W MAIN STREET C",7STATE,21P RIPON CA 95366 _ <br /> SUBCONTRACTOR PHONE ! <br /> SUBCONTRACTOR ADDRESS CITY/STATEjZZP <br /> LICENSE C-57 C-51 D-09 XOtrer C10 NUMBER 662732 EXPIRATION DATE 01/31/19 <br /> GEOGRAPHICAL INFORMAnoN: Coordinates X Y Township_ Range_-__ Section_ <br /> INTENnEn USE X DDmestVPnvate IrrigatioNAgnculturai I industrial .:.Water Quality Moni.onng Soil$ampangiCharacterLauon <br /> Public Water System <br /> *CCeror;t tryr Owns:' =, y m a�w! ?Tarilc aiPiAu urr.,u; <br /> TYPE OF WoRx New Wail Replacement Wel Well AlteratiorlModnceGon Caner <br /> t c:tlMMsf or r '.'Js <br /> Soil S=g{s; eo;e=hn:u.: <br /> Out-Of-Service Well Ou OfService Wel:Renew i Cross-Cornectfon Repair <br /> New Pumg X Pumo Replacement Pump Repair Raise Wei;Cas+nq <br /> W EL L CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point vtrer I <br /> Proposed Well Depth t, Excavation n diameter Open Bottom Gravel PedciGravel Size in dtarneterl I <br /> COnduCtar Casng in diameter / Conductor Casing Depth ft <br /> Wel!Casing Dlarneter_m Tnicknass/Gauge/ASTM Schee Steel Piesbc Stainless Slee! Other <br /> Grout Soai Depth f! Neat Ccment(941b bag 5-10 galwater) Sand Cement &k ck mrxF7 ga;wd:er, <br /> Bentonite(20%solids) : Other <br /> Grout Placement Method Pumped Free Fail .Other Retardant,'Accelerator(name) ! <br /> II <br /> i <br /> P£OESTAI instatied By Driller . Pump Contractor Other <br /> Concrete Pedestal Ointensions.VJdtn It Length tt Thick_ _in _ Christy Box Stove Pipe--J! <br /> PLYP Suomers:bie.. Turbine .Other HP--j_ Pump Se: Rfl R S:ar,aing Water Level <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN I <br /> U COUNTY 0 iNANCES,STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THA' MY REQUIRED LICENSE IS ; <br /> D AC WITH THE LIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AN IN COMPLIANCE WITH ALL <br /> RS C'PMPEN ON LAUM OUR A/ E/rJ�'O 1 REQUIRED FO I'r�I$PECTiONNS-PLEASE CALL(209) 3-767!U:RRENT <br /> GNED / v v �� TITL- DATE <br /> N ! 1 f7 <br /> E !1741 &1 1 1 ii11 1 I I I ! I JI <br /> SI 11 ! I II <br /> I I i <br /> ( &EIVED <br /> N I I <br /> � G� `SIF ! II I I if I I I I I ME�ITALHEALIH <br /> R� 1 1 r 1 IT/SERVICES <br /> ♦' �: � to � ; i I � � ! ! <br /> un .4pt,.'� <br /> I I <br /> I <br /> TMENT U/YApplicaGonP�eptedBy Da!e �l � Area EmptoyaelDi'�,7 <br /> Grout Inspection By. Daze_ SPECIAL Well Permit YYY <br /> Pump Inspection By Date WAIVER Received <br /> Soil BoringI ticn By 'e <br /> Constructed Well Depth_ N <br /> COMMENTS lr ��r� n/<• <br /> PE Sc ReceivedChec Amount DatePermitt Invoiced Well ID# <br /> Codes Inco sh Remitted Service Reatitast# I I <br /> 0 t@?5y <br /> enD�i ttE 'WELL PUMP KRMIT <br /> tlJ9l:2 <br />