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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 /> H <br /> JOB ADDRESS 25100 E. River Road Clry/ZIP Escalon 95320 <br /> D <br /> CROSS STREET McHenry Avenue APN 24709015 PARCEL SIZE 44 LAND USE APPLICATION# NIA O <br /> A <br /> OWNER NAME CITY OF ESCALON PHONE 209-933-7000 y <br /> OWNER ADDRESS 2060 MCHENRY AVENUE CITY/STATE/Zip ESCALON,CA 95320 <br /> CONTRACTOR WALLACE-KUHL&ASSOCIATES PHONE 916-372-1434 <br /> 1 CONTRACTOR ADDRESS 3050 INDUSTRIAL BLVD CITY/STATE/Zip WEST SACRAMENTO,CA 95691 <br /> SUBCONTRACTOR MIDDLE EARTH GEO TESTING, INC. PHONE 714-663-5025 <br /> SUBCONTRACTOR ADDRESS 954 N. Lemon Street CITY/STATE/ZIP Orange,CA 92867 <br /> LICENSE X C-57 ❑C-61 LI D-09 1 Other NUMBER 899451 EXPIRATION DATE 6/30/21 <br /> DOMESTIC WELL SAMPLING:!-1 General Mineral/Coliform Bacteria(4391)rr'Dibromochloropropane(4392)rl Arsenic(4393) <br /> INTENDED USE I Domestic/Private C1 Irrigation/Agricultural 11 Industrial I_ Water Quality Monitoring X Soil Sampling/Characterization <br /> j Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK 7 New Well D Replacement Well Well Alteration/Modification I Other <br /> 7 Monitoring Well(s) #of wells I Soil Boring(s) #of borings Xi Geotechnical 7 #of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pum -1 Pump Replacement Pump Repair Raise Well casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary -1 Ar Rotary X Auger I Cable Tool i Push Point Other <br /> Proposed Well Depth 50 It Excavation # ;._in diameter a Open Bottom _Gravel Pack/Gravel Size in diameter <br /> 1 Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad 1-1 Steel ! Plastic I Stainless Steel 7 Other <br /> Grout Seal Depth 50 It X Neat Cement(94 1b bag15-10 gal water) Sand Cement sack mix17 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method 7 Pumped X Free Fall u Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller i i Pump Contractor i Other _ <br /> Concrete Pedestal Dimensions:Width ft Length It Thick in L Christy Box L 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 /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS, I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> 7?1 M $HOUA A VANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE SENIOR ENGINEER DATE <br /> yMENT <br /> CEIVED <br /> 0 9 2019 <br /> QUIN COUNTY <br /> Chn,pONMENTAL <br /> DEPARTMENT <br /> wA M E N T�G�?�%C �Y <br /> Application Accepted By Date Are�T//`r Employee ID#��V <br /> Grout Inspection By ____ __ Date SPECIAL 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/ <br /> Codes Info Bv A Cash Remitted Date Se ice R 1#_ Invoice# Well ID# <br /> /111 `' / <br /> EHD 43-06 revised 4/14/16 WELL/PUMP PERMIT <br />