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P V/ <br /> c 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 /> JOB ADDRESS 0007 E ZUMWALT CITY/ZIP ESCALON, 95320 <br /> D <br /> CROSS STREET CARROLTON RD APN 0 PARCEL SIZ# ND USE APPLICATION# <br /> OWNER NAME LARRY WOLTJER $ �tJ��1 'r ��7777 PHONE 2 09.8 38.3431 y <br /> OWNERADDRESS 19467 SEXTON RD CITY/STATE/ZIP 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/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 Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner. Water System Name on a ame or Prone um er <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification i Other <br /> MonitoringWell(s) #of wells SoilBoring(s) #otbormgs Geotechnical #of borings <br /> Out-Gf-Service Well Otd-01'-Servica Well Renew./ Cross-Col Inaction Repair <br /> New Pump 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 It <br /> Well Casing Diameter in Thickness/Gauge/ASTM Schad Steel i Plastic Stainless Steel Other <br /> Grout Seal Depth ft Neat Cement(94 lb bag/5-10 gal water) Sand Cement sack mixR gal water <br /> Bentonite(20%solids) Other r91 <br /> t7 <br /> Grout Placement Method Pumped Free Fall Other Retardant/Accelerator(name) T <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width ft Length ft Thick in Christy Box Stove Pipe M <br /> CD <br /> PUMP XSubmersible. Turbine Other HP-3- Pump Set ft Standing Water Level ft <br /> 1 HEREBY CERTIFY TAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN C <br /> JOAQUIN COUNTY INANCES, STATE LAW D RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS G� <br /> CU AND AC V WIT T CALIFOR A CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL F---� <br /> W RKER COMPE ION L W . <br /> M U 4 OU NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLEI� 4Td AyV� DATE A l <br /> N <br /> WI E <br /> S <br /> et L <br /> RECEIV <br /> a,G OUIN COU <br /> S�L MENT E O LY <br /> 5r�.1��RpNME��FF"h�i <br /> HFA=TN DEPATlcalion Accepted Date ( Area Employee ID#f�� <br /> Grout Inspection By 01 DateSPECIAL Well Permit <br /> Pump Inspection By Date� _ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check# Amount Permit/Codes Info B emitted Date Service Request# Invoice# Well ID# <br /> S-0 a.S70L7 g� Lb 37Z�9J <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4130112 <br />