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WELL/PUMP PERMIT i/-//36 <br />^` SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue - STOCKTON CA 95205-6232 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 21413 S. Harrold Ave ciTY/ZIP Escalon 95320 <br />CROSS STREET East River Rd APN 247-210-04 PARCEL SIZE AND USE APPLICATION # <br />OWNER NAME Joesph Adrian PHONE 402-4972 <br />OWNER ADDRESS 26554 E River Rd CITY/STATE/ZIP Escalon.. CA 95320 <br />CONTRACTOR Hennings Bros. Drilling Co., Inc. PHONE 209-545-1185 <br />CONTRACTOR ADDRESS 1930 Ladd Rd CITYISTATE/ZIP Modesto, CA 95356 <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS CITYISTATE/ZIP <br />LICENSE X C-57 C-61 D-09 Other NUMBER 290813 EXPIRATION DATE 05-31-2017 <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br />JTENDED USE X DomeslicJPrivate C''. Irrigation/Agricultural F Industrial Water Quality Monitoring :1 Soil Sampling/Characterization <br />7 Public Water System <br />If different from Owner: Water System Name Contact Name or Phone um er <br />YPE OF WORK k New Well Replacement Well L Well Alteration/Modification -1 Other <br />Monitoring Well(s) # of wells n Soil Boring(s) ° °w' E Geotechnical <br />7 Out -Of -Service Well C Out -Of -Service Well Renewal ❑ Crass -Connection Repair <br />Drilling Method )� Mud Rotary -1 Air Rotary C Auger P Cable Tool n Push Point :1 Other <br />Proposed Well Depth 250 It Excavation 14 in diameter r1 Open Bottom R Gravel Pack/Gravel Size 6/8 Blend in diameter <br />i Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter 8 in Thickness/Gauge/ASTM Sched SDR26 1 Steel R Plastic ❑ Stainless Steel D Other <br />Grout Seal Depth 100 It D Neat Cement (94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix77 gal water <br />X Bentonite 20% solids) , Other <br />Grout Placement Method Pumper' Free Fall j Other i Retardant / Accelerator (name) <br />PEDESTAL Installed By D Driller 5t Pump Contractor a Other <br />Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑ Christy Box r! Stove Pipe <br />PUMP .1 Submersible D Turbine 1=1 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 />'u1 t�. M�� <br />MINIMUM 24 HOUR ADVANCE E REQUIRED FOR INSPECTIONS Q <br />SIGNED [l wv�1VT M1di- Oa►Y11.b r I ITLE �/ �. DATE <br />5r"� <br />Application Accepted BX <br />Grout Inspection By <br />Pump Inspection By <br />foil Baring Inspection By <br />Date <br />Date <br />Iq) <br />D <br />0 <br />0 <br />m <br />N <br />JN <br />I� <br />j <br />Area_qq�_ EmployeelD#0 <br />PECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth ft <br />PE SC Received <br />Codes Info B <br />Amount Date Permit/ Invoice # Well ID# <br />ash Remitted Service Request # <br />3�3 <br />t!�aSB r - ' 5' I �t� Wpbo3(e(�q <br />•60s <br />q e <br />/ ►I it <br />EHD 43-06 <br />8/04/08 <br />WELL /PUMP PERMIT <br />