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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 /> Joe ADDRESS:T .747-64 E.Rover Road CITY/ZIP Escalon,CA m <br /> CROSS STREETMTV 11 r I''r:� APN�` 9 w !D� PARCEL SIZE./' 1 h LAND USE APPLICATION# p <br /> m <br /> OWNER NAME City of Escalon PHONE m <br /> OWNER ADDRESS 2060 McHenry Avenue CITY/STATE/ZIP Escalon,CA <br /> CONTRACTOR Krazan$ASSDCJates.Inc. PHONE 559.8&2200 <br /> CONTRACTOR ADDRESS 215 W.Dakota Avenue CITY/STATE/ZJP Clu:is,California 93612 <br /> SUBCONTRACTOR Krazan&Associates,Inc. PHONE 559'348.-21200 <br /> SUBCONTRACTOR ADDRESS 215 N/ Dak-Ia Avenuc CITY/STATE/ZIP Clovis.Caliimnia`131+12 <br /> LICENSE /C-57 C-61 D-09 Other NUMBER -,_ig,tOf' EXPIRATION DATE 10.31 2021 <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE DomeslicJPrivate Irrigalion/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If d Ift—1 I—Owner. Waler System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well Replacement Well Well Alleration/Modification Other <br /> Monitoring Well(s)el;;; #of wells Soil Bonng(s) #of borings V Geotechnical 5 #of bonngs <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair (20-50 Feet) <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.f ft Excavation in diameter Open Bottom Gravel Park/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br /> Grout Seal Depth fl ./Neat Cement(94 lb bag/5-10 gal wafer) Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method,/Pumped l Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width 9 Length it Thick in Christy Box Stove Pipe <br /> PUMP Submersible Turbine Other HP Pump Set it Standing Water Level it <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 /> M NIMUM 46 HO ADVA TICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> c-)---�— <br /> SIGN TITLE Managing Engineer DATE 11/12/2020 <br /> MINT <br /> FD <br /> 2020 <br /> pTMENT Y <br /> NT <br /> DEPARTMENT USE ONLY <br /> Application Accepted ByDale ��� ��,� <br /> -''''�' 0�0 Area T/L'i! '', Employee ID# �1 e- <br /> ���`,,` <br /> Grout Inspection By - Date I r SPECIAL Well Permit <br /> Pump Inspection By Date ' r WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well/Depth ft <br /> COMMENTS-f(—C4PeP61✓ *1 k_40 30 d? Oy �^/Ji'— LJ�S �:�Gh !itr1(7 Y/C',31 ndc pi g <br /> PE SC Received Chec Amount Date Permit/ Invoice# Well ID# <br /> Codes Info - Remitted I Service Request# <br /> 1�'7 IaU r'! ZZD W <br /> EMD 43-06 revised 4114/18 WELL rPUMP PERMIT <br />