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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE • STOCKTON CA 95205 -6232 (209) 468-3420 <br />N-KEFUNDABLE PERMIT www.sjgov.org/ena tAF lKtS 7 YEAR FROM UATE ISSUED <br />ADDRESS 770 Frontage Road CITY/ZIP Ripon 95366 <br />SS STREET Arc Way APN 261-050-01 PARCEL SIZE t 55 acres LAND USE APPLICATION # <br />ER NAME Jaswant S. Sekhon PHONE <br />ER ADDRESS P.O. Box 466 CITY/STATE/ZIP Salida, CA 95368 <br />RMA Geoscience, Inc. <br />CToR ADDRESS 3897 North Ann Avenue <br />CITY/STATE/ZIP <br />PHONE (559)708-8865 <br />Fresno, CA 93727 <br />TRACTORICONSULTANT Salem Engineering Group PHONE <br />TRACTOR/CONSULTANT ADDRESS 4729 W. Jacquelyn Avenue CITY//STATE/ZIP Fresno, CA 93722 <br />X C-57 C-61 D-09 Othef NUMBER 970772 EXPIRATION DATE 03131/202? <br />PARTY: OWNER X CONTRACTOR SUBCONTRACTORICONSULTANT <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE Ucmesbc/Rnvale Imgatlon/Agncultural Industrial Water Quality Monitoring .K Soil Sampling/Characterization <br />Public Water System <br />It NNerent from Owner Water System Name Contact Name or Phone Number <br />TYPE OF WORK New Well Replacement Well Well AJteration/Modification X Other Geotechnical Investigation <br />Monitoring Well(s)# of wells Soil Borings) •otbonngs X Geotechnical 2 to 20' a of bonny <br />Out -Off -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />w rump a rump meplacemem rump reepa❑ Kaise Wen Casing <br />WELL CONSTRUCTION No wells will be installed. Just two (2) geotechnical borings to 20'. <br />Drilling Method Mud Rotary -. Air Rotary X Auger Cable Tool Push Point Other <br />Proposed Well Depth 20 ft Excavabon 7 in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter i Conductor Casing Depth ft <br />Well Casing Diameter _ in ThicknesslGauge/ASTM Sched Steel Plastic Stainless Steel Other <br />Grout Seal Depth d(� ft X Neal Cement (941b bag/5-10 ga' water) Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method X Pumped Free Fall Other Retardant / Accelerator (name) <br />(PEDESTAL Installed By Driller Pump Contractor Other <br />f n1a Concrete Pedestal Dimensions-. Width ft Length ft Thick in Christy Box Stove Pipe <br />�LPuMp n/a Submersible Turbine Other HP Pump Set ft 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 />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 />WORKERS COMPENSATION LAWS. <br />y�1�j'�j�}IJMIU �HHOOURRy—p�j�'�`7�''/ANCE NOTICE REQUIRED FOR INSPECTIONS <br />IIN7SPECTION��S - PLEASE CALL (209) 7953-7697 <br />SIGNED CrC�C rITLE� % / LIc, 4t4gln DATE L'23 <br />DEPARTMENT USE ONLY ,, ``11 <br />Application Accepted By nf� z -_ Date S s � / Area K I � � . Employee ID# �s f <br />Grout Inspection By C42 �G' Date 91j312! SPECIAL Well Permit <br />Pump Inspection By Date WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />PE <br />Codes <br />Sc Received <br />Info <br />Check#/ Amount Date Perri Invoice # Well ID# <br />ash' Remitted S ice a est 17 <br />-71 <br />EHD 17-06 6rI112e19 /-� � � / 1 y / WELL RUMP PERMIT <br />1 YMENT <br />CE/ VE� <br />05 Z421 <br />pMENTC0 LINT Y <br />A� TME/VTI <br />