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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 /> o <br /> JOBADDRESS17266 French Camp Rd. CITY/ZIP Ripon 95366 `4 <br /> m <br /> CROSS STREET N. of Yosemite Ave. APN 203-22-079 PARCEL SIZE 2'00 LAND USE APPLICATION# 0 <br /> OWNER NAME Arvin &Terri Boersma PHONE '09-324-1116 Dayna m <br /> OWNER ADDRESS 15826 E. Hwy 120 CITYISTATE/ZIP Ripon, CA 366 <br /> CONTRACTOR Hennings Bros. Drilling Co., Inc. PHONE 209-545-1185 <br /> CONTRACTOR ADDRESS 1930 Ladd Rd. CRY/STATE/ZIP Modesto, CA 95356 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C-57 C-61 ❑ 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/Pnvate 1 Irrigation/Agricultural ❑ Industrial E 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 u Replacement Well ❑ Well Alteration/Modification a Other <br /> Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of borings <br /> _i Out-Of-Service Well ❑ Out-Of-Service Well Renewal G Cross-Connection Repair <br /> New Pum i] Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary ❑ Air Rotary i-I Auger ❑ Cable Tool Push Point ❑ Other <br /> Proposed Well Depth -3o, ft Excavation in diameter !] Open Bottom Gravel Pack/Gravel Size r <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft RECEIVED <br /> Well Casing Diameter'" in ThicknessfGaugeIASTM Sched SDR21 ❑ Steel C Plastic ❑ Stainless Steel D, Other <br /> Grout Seal Depth 100 o ft ElNeat Cement(94 lb bag/5-10 gal water) L, Sand Cement qj fnixt!2al <br /> Bentonite(20%solids) 11 Other ((jJUU LL <br /> Grout Placement Method t1 Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By fl Driller L. Pump ContractorOther <br /> I Concrete Pedestal PDimensions:Width ft Length ft Thick <br /> �in 'J Christy Box ❑ Stove Pipe <br /> PUMP CI 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 lof proposed well. <br /> ua, FOIA- '-PECTIO;r,••.i_EASE CALL(209)953-7697 <br /> } DEPARTMENT USE ONLY <br /> Application Accepted By / ' " " Date Area Employee ID#�— <br /> Grout Inspection By Date 3� Z 4 ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS % -.JGL( �LL> <br /> PE SC Received Check#/ Amount Date PermlU Invoice# Well ID# <br /> Codes Info B Ca h Remitted Service Request# <br /> A� VJ NIP 3+11105, <br /> W,i'yt gLl1 <br /> Ee[w43-06 tori-5/2021 Page I ,r2 W01 i Pump P�runt <br />