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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PER T CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> / to <br /> JOB ADDRESS 19116 LONE TREE RD CITY/ZIP ESCALON, 95320 n <br /> ~ ROSS STREET CARROLTON RD APN D bo <br /> PARCELSIZ�5— <br /> LAND USE APPLICATION# m <br /> LWNERNAME DOORNENBAL DAIRY PTP PHONE 613.6605 y <br /> C4 ROWNERADDRESS 19116 LONE TREE RD CITY/STATE/ZIP ESCALON, CA 95320 <br /> W ONTRACTOR N&S IRRIGATION, INC PHONE 209.599.3456 <br /> r <br /> ONTRACTOR ADDRESS 215 W MAIN STREET CITY/STATE/ZIP RIPON, CA, 95366 <br /> O <br /> 1,�� �_ UBCONTRACTOR PHONE <br /> Z SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C-57 C-61 D-09 XOther C10 NUMBER 662732 EXPIRATION DATE 01/31/19 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br /> INTENDED USE X Domestic/Private I Irrigation/Agricultural Industrial r--!Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone um er <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification XOther REPLACED MOTOR ONLY <br /> Monitoring Well(s) #of wells Soil Boring(s) #of bonngs Geotechnical #of borings <br /> Out-Of-Service WellPut-Of-Service Well Renewal Cross-Connection Repair <br /> New rum Pum Re lacement "urn Repair Raiae Well Cason <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Well Depth ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched Steel Plastic i Stainless Steel Other <br /> Grout Seal Depth ft Neat Cement(94 Ib bag/5-10 gal water) Sand Cement Sack mix17 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width ft Length It Thick in Christy Box Stove Pipe <br /> PUMP Submersible Turbine Other HP­ Pump Set 141 It Standing Water Level_BD _It <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOA COUNTY DINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> C REN AND TI WI H T E CALIFORN CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> ORKER COMP NS TIO LA <br /> IM U H NOTICE REQUIRED FOUR INSPECTIONS-PLEASE CALL(209)953-7697 (J(/ <br /> SIGNE TITLE I 't `\�/�1�` ,V DATE <br /> tt <br /> N <br /> 1E1 I tm tI A7 <br /> S - -- <br /> PAe;ES <br /> �Eg 15 <br /> SPS I NO I <br /> RNIN <br /> kf T <br /> HPpI.TH DEP �i <br /> l� <br /> JERT]MENT SE N L Y <br /> Application Accepted By ateJIJA <br /> Area Employee ID#ZL/j&� <br /> Grout Inspection By Date I PECIAL Well Permit <br /> Pump Inspection By y Date I i 1 PIA WAIVER Received <br /> Soil Boring Inspection By Date ` t_ ` V Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Amount Date PermiU Invoice# Well ID# <br /> Codes Info B sh Remitted Service Request# <br /> 2a� / <br /> WP <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4130112 <br />