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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 PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> E D <br /> JOB ADDRESS 20455 ALLEN RD CITY/ZIP ESCALON, 95320 D <br /> �✓ <br /> 2 0 <br /> CROSS STREET S.VAN ALLEN APN�J 45-030' 06 PARCEL SIZE 1•J LAND USE APPLICATION# m <br /> OWNER NAME • HALE L[fre'/LL PHONE 209.599.7546 <br /> OWNER ADDRESS 20455 ALLEN RD CITY/STATEIZIP ESCALON CA. 95320 <br /> CONTRACTOR N &S IRRIGATION, INC PHONE 209.599.3456 <br /> CONTRACTOR ADDRESS 215 W MAIN STREET CITY/STATE/ZIP RIPON, CA, 95366 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATEIZIP <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 Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner Water System Name Contact Name or Friona Numoer <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br /> MonitoringWell(s) _#of wells SoilBoring(s) #of borings Geotechnical _#of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump X Pump Replacement Pump Repair Raise Well Casing <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 i Steel Plastic i Stainless Steel i Other <br /> Grout Seal Depth it Neat Cement(94 lb bag15-10 gal water) Sand Cement sack nI 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 ft Thick in Christy Box Stove Pipe <br /> PUMP XSubmersible Turbine Other HP__a_ Pump Set 100 ft Standing Water Level <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 /> CU3ND ACT' E WITH THE CALIFORNIACONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WO MPEN T'ON A <br /> U 4 HO A V N NOTICE REQUIRED FOR I(2 NSPECTIO_ NLS-gLEASE CALL(209)953-769 <br /> SIGNED TITLE ,y�/� DATE <br /> N <br /> E •� <br /> S <br /> t— c] N oU LU O <br /> LU _> U <br /> I.2 W Z <br /> Q o v 00Zw <br /> ¢� <br /> Ix <br /> ZLU <br /> DEP RT ENT U E 9NLY G '/'�/,c/�/� �j/,, 11T <br /> Application Accepted By bmtoArea Employee ID#4waa � <br /> NNNJJJ <br /> Grout Inspection By Date SPECIAL Well Permit r <br /> Pump Inspection By L Date G WAIVER Received (\� <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Chec Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B ash Remitted Service Request# <br /> OW-9 <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4/30/12 <br />