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� ✓ r �I U <br /> WELL/PUMP PERMIT <br /> SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1668 EAST HAZELTON AVENUE-STOCKTON CA 95205- 209 468-3420 <br /> ( ) <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 22095 HWY 120 CITY/ZIP ESCALON, 95320 <br /> CROSS STREET SEXTON RD AP IN W�LIl�LJ PARCELSIZE LAND USE APPLICATION# <br /> OWNER NAME A.D.P. DE PALMA Z N PHONE 838.7034 y <br /> OWNER ADDRESS 18666 E. HWY 20 L22o 9S 6, 14ky /Z6 CITY/STATE/ZIP RIPON, CA. 95366 gS3LC) <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 i D-09 XOther C10 NUMBER 662732 EXPIRATION DATE 01/31/19 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section <br /> INTENDED USE Domestic/Pdvate Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water System Nam on a ame or one um r <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells 1 Soil Boring(s) #of bonngs Geotechnical #of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair PAYM <br /> New Pum X Pum Replacement Pum Repair Raise Well Casing ^ /r�/s <br /> WELL CONSTRUCTION �6q .r <br /> Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other C F® <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 IV 08 <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad !Steel Plastic i Stainless Steel Other �i� 201 <br /> Grout Seal Depth ft Neat Cement(94/b bag/5-10 gal water) Sand Cement sack m&17 gatw� v QLl//V <br /> Bentonite(20%solids) Other !Y / Ojv O UN7y <br /> Grout Placement Method Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other FNT <br /> Concrete Pedestal Dimensions:Width ft Length ft Thick in Christy Box Stove Pipe <br /> PUMP XSubmersible, Turbine .'Other HP 5 Pump Set 105 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 /> JO COUN ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> C REN ND IVE VVIT MTHE CALIFOR A CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> ORKERS OM E SA-nCP S. <br /> M IM CE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209), 3-7697/I <br /> / <br /> SIGNED TITLE r DATE 1 <br /> N <br /> E <br /> S (11AAV 101V <br /> RECE 011 <br /> JAN 0 3 <br /> ENVIRONMENT <br /> PERMIT/SE <br /> #( <br /> DE ARTMENTUS O LYjk <br /> Application Accepted By Date S. Area s Employee ID#�:M <br /> Grout Inspection By ,a� Date SPECIAL Well Permit <br /> Pump Inspection By t�5v 'V"4 Date WAIVER Received <br /> Soil Bonn Inspection By Date Constructed Well Depth ft <br /> COMMENTS C \o e � <br /> PE SC Received Che Amount Permit/ <br /> Codes Info B emitted Date Service Re uest# Invoice# Well ID# <br /> a ?�- IT w FC <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4/30112 <br />