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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)4684420 <br /> NON-REFUNDABLE <br /> pPEER �/,11 <br /> MIIT Www.S ov.of /ehd EXPIRES YEAR FROM DATE ISSUED <br /> Joe ADDRESS /$3, ;33L ( 7CITYRrP Sji CikLOr A, gdL)1J <br /> D <br /> CROSS STREET l�clA - RCAPN 'J <br /> LAND USE APPLICATIONS, <br /> p <br /> OWNER NAME Brazil a Van Ryn Dairy LLC PHONE (209)482.2295 <br /> OWNER ADDRESS P.O.Box 149 CrTYISTATE/LP Ripon,CA 95366 <br /> CONTRACTOR Nor-Cel Pump d Well Drillino.Inc. PHONE (5301674-5861 <br /> CONTRACTOR ADDRESS 1325 Barry Road CITY/STATE/ZIP Yuba City,CA 95993 <br /> SUBCONTRACTOR/CONSULTANT rVa PHONE <br /> SUBCONTRACTORICONSULTANT ADDRESS CITY/STATEZP <br /> LICENSE XC-57 XC-61 XD-09 Other NUMBER 908591 EXPIRATION DATE 01/31/20 <br /> BILLING PARTY: XOWNER CONTRACTOR SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING: General MlneraVColiform Bacteria(4391) Dibromochloropropane(4392)_Arsenic(4393) <br /> INTENDED USE Domestir/Privale X Irrigation/Agricullurai Industrial Water Quality Monitoring Soil SamplinyCharacterizalion <br /> Public Water System <br /> 116Merenl ham Owner: Wales System Nsms Conlsd Nems or Phan.Numbs, <br /> TYPE OF WORK XNew Well . Replacement Well Well AlterationrModihcatton Other <br /> MonitoringWell(s) 0ofwells SoilBodng(s) 9&bO1lns' Geotechnical eo1bonoa' <br /> Out-Cf-Service Well Out-Of-Service Well Renewal - Cross-Connection Repair <br /> -(New Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method X Mud Rotary Air Rotary Auger Cable Tool Push Point -_ Other <br /> Proposed Well Depth 450' n Excavation 2a In diameter - Open Bottom x Gravel Pack/Gravel Size TBD In diameter <br /> Conductor Casing in diameter / Conductor Casing Depth I <br /> Wall Casing Olameter in IThickness/Gauge/ASTM Sched .250 X Steel . Plastic .. Stainless Steel Other <br /> Grout Seat Depth R Neat Cement(94 Ib bag/5-10 gal waler) Sand Cement sack mlx77 gal water <br /> Bentonite(20h solids) Y Other 10.3 sack <br /> Grout Placement Method 31 Pumped . Free Fall _Other -Retardant/Accelerator(name) <br /> PEDESTAL Installed By - Driller .x Pump Contractor Other <br /> .X Concrete Pedestal..Dimensions:Width 5 n Length 5 it Thick 5 in ; Christy Box ' Stove Pipe <br /> PUMP SUbmerslble:X Turbine Other HP 75 HP Pump Set 10 D R Standing Water Level Uakrxxl M <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 TTVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE HOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMP SATION LAWS. <br /> MINIM 8 HOU DVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE Nar Hear,Pres(denVCEO DATE 12116119 <br /> 2 <br /> YMENT <br /> E'`VEE <br /> 2 0 2019 <br /> �( QUIN COUNTY <br /> EI V RONMENTAL <br /> T DEPARTMENT <br /> I <br /> EP TMLj <br /> ENT tfSE PNLY <br /> Application Accepted By ale Area Employee IDI <br /> Grout inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth h <br /> COMMENTS i <br /> PE Sc Receive Ighlellillf Amounta Parmitt Invoice M Well IDM <br /> Codes Info Cash emitted Smite Regest M <br /> D <br /> d ("ZIA W?0040 41 <br /> EHD.` 0 6n,2019 WELL RUMP PERMIT <br />