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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232 (209)468-3420 <br /> NON-REFUNDABLE PERMIT www.Sigov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 17597 Beeler Road CITY/ZIP Escalon 95320 m <br /> b <br /> 0 <br /> CROSS STREET HWY 120 APN 229-030-230-000 PARCEL SIZE 19 39 Acres LAND USE APPLICATION# 0 <br /> m <br /> OWNER NAME Daniel P & Lori M Gust PHONE (209)601-3712 <br /> OWNER ADDRESS 17597 Beeler Road CITYISTATEIZIP Escalon, CA 95320 <br /> CONTRACTOR Daniel P and Lori M Gust PHONE (209)601-3712 <br /> CONTRACTOR ADDRESS 17597 Beeler Road CITY/STATE/ZIP Escalon,CA 95320 <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATEIZIP <br /> LICENSE ❑ C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER EXPIRATION DATE <br /> BILLING PARTY: XOWNER ❑CONTRACTOR ❑ SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391)❑ Dlbromochloropropane(4392)C Arsenic(4393) <br /> INTENDED USE X 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 Phone Number <br /> TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) <br /> #of borings ❑ Geotechnical #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> New Pum ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool a Push Point ❑ Other <br /> Proposed Well Depth ft Excavation In diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br /> ❑ Conductor Casing in diameter I Conductor Casing Depth ft <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Schad ❑ Steel I I Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth ft ❑ Neat Cement(94/b bagl5-10 gal water) u Sand Cement sack mix/7 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method U Pumped C Free Fail ❑ Other a Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal❑Dimensions Width ft Length ft Thick in I_I Christy Box r� Stove Pipe <br /> PUMP Submersible❑ Turbine ❑ 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 /> JOAQUlN COUNTY ORDINANCESSTATE LAWS, AND RULES ANb REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH TH,E CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. r1 <br /> r• --,w .. `:-i—.:yam'.. w" i - .fE�.i''-s�e�. <br /> �L�/ /"LY <br /> SIGNEL�.O /' TITLE -- <br /> DATE <br /> a- <br /> ----------------- <br /> WENT <br /> Sw jobaJIN <br /> Tqr&LT- R M <br /> P RTMENT U EIN L Y -�� <br /> ����//�� <br /> Application Accepted By Date Area Employee ID#AW6f1H`'r <br /> Grout Inspection By Date PECIAL Well Permit <br /> Pump Inspection By w '3� ��Vmd,vli Date �� WAIVER Received <br /> Soil Boring Inspe 9tion By Date Constructed Well Depth ft <br /> COMMENTS �b e-!j42'7 <br /> PE Sc Received Check#/ Amount Permit/ <br /> Codes Info B Cash Remitted Date Service Request# Invoice# Well ID# <br /> Mcaacet.Lal. AIGLSAO.A. 3 <br /> *� q5 0 (000 <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />