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1 WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> N <br /> JOB ADDRESS 17266 French Camp Rd. CITY/ZIP Ripon 95366 m <br /> D <br /> CROSS STREET N. of Yosemite Ave. APN 203-22-079 PARCEL SIZE �'�� LAND USE APPLICATION# a <br /> OWNER NAME Arvin &Terri Boersma PHONE 209-324-1116 Davna m <br /> OWNER ADDRESS 15826 E. Hwy 120 CrrylSTATE/ZIP I`iuoIi, CA�5366 <br /> CONTRACTOR Hennings Bros. Drilling Co., Inc. PHONE 209-545-1185 <br /> CONTRACTOR ADDRESS 1930 Ladd Rd. CrrY/STATE/ZIP Modesto, CA 95356 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATE/ZIP <br /> LICENSE C-57 h C-61 11 D-09 r, Other NUMBER 290813 EXPIRATION DATE May 31, 2024 <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE " Domestic/Private ❑ Irrigation/Agricultural FlIndustrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> ❑ Public Water System <br /> If different from Owner. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ❑ New Well Replacement Well ❑ Well Alteration/Modification a Other <br /> =i Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings i_l Geotechnical #of borings <br /> Out-Of-Service Well O Out-Of-Service Well Renewal I_, Cross-Connection Repair <br /> New Pump u Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method i�Mud Rotary ❑ Air Rotary r 1 Auger ❑ Cable Tool ❑ Push Point 1 Other <br /> Proposed Well Depth 250 It Excavation - in diameter ❑ Open Bottom Gravel Pack/Gravel Size r <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft DECEIVED <br /> Well Casing Diameter P' in Thickness/Gauge/ASTM Sched SDR21 I,] Steel C Plastic 1.1 Stainless Steel 0 Oth r <br /> Grout Seal Depth 100 ft Neat Cement(94 Ib bag/5-10 gal wafer) _1 Sand Cement sack�ixfl gal <br /> i' Bentonite(20%solids) ; Other �(JJ Li <br /> Grout Placement Method X Pumped ❑ Free Fall ❑ Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor _. Other <br /> C Concrete Pedestal[-]Dimensions:Width ft Length ft Thick <br /> in Christy Box 0 Stove Pipe <br /> PUMP C Submersible❑ Turbine � Other HP Pump Set ft Standing Water Level ft <br /> Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect to the following items: GPS <br /> Coordinates, property lines, adjoining properties, water bodies or courses, drainage pattern, roads, existing wells, structures, <br /> potential sources of contamination, sewers or private disposal systems. Include distance from two property lines. For Domestic, <br /> Agriculture,Industrial well,provide location of any water wells or surface water within 200'radius of proposed well. <br /> ::ii:.L',W.f_'ti i jOL:<ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date ��Z L� 3 Area ��1 Employee ID#� <br /> Grout Inspection By Date 4 ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS I`' ���1 ✓ d I'`t`tom"� t K �t yC <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> gCodes Info . By C h Remitted Service Re uest# <br /> ZJ C <br /> VIC <br /> U 1 <br /> PIfU043-06 10/2512021 I'age I of 2 Well 1 Pump Permit <br />