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WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 hUK INSYtG I TUNS CAh'IRCJ '1 T tAK hKUM UA I t ISSUCU ADDRESS 1055 Escalon Avenue a CITY/ZIP Escalon, CA m SS STREET �) IeY AV'Q. APN ✓' t�a PARCEL SIZE lo'078LAND USE APPLICATION# NAME City of Escalon ADDRESS 2060 McHenry Avenue Krazan &Associates,lnc. ADDREss 215 W. Dakota Avenue ��e Krazan &Associates,lnc. ADDREss ?_1 `' Nl. Dakota Avenue LICENSE � C-57 a C-61 ❑ D-09 ❑ CITY/STATE/ZIP Escalon, CA 559.346.2zoo CITY/STATE/ZIP Clovis, California 93612 PHONE 559.348.2200 CITY/STATE/ZIP Clovis, California 93612 NUMBER 499908 EXPIRATION DATE 10.31.7.021 DOMESTIC WELL SAMPLING: ❑General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) r� Arsenic (4393) INTENDED USE a DomestidPrivate ❑Irrigation/Agricultural Ll Industrial [I Water Quality Monitoring c! Soil Sampling/Characteri zation Ll Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK ❑New Well is Replacement Well 11 Well Alteration/Modification 11 Other ❑ MonitoringWell(s) #of wells ❑ Out -Of -Service Well n Naw Pumn n Pumn Rpnlarpmpnf ❑ SoilBoring(s) #of borings v/ Geotechnical 2 #of borings ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair (20-50 Feet) F1 Pumn Renoir r] Raise Well Casinn WELL CONSTRUCTION Drilling Method ❑ Mud Rotary ❑ Air Rotary %/ Auger ❑ Cable Tool El Push Point 1 Other Proposed Well Depth a3'S3 ft Excavation in diameter I. Open Bottom a Gravel Pack/Gravel Size in diameter ❑ Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter. in Thickness/Gauge/ASTM Schad ❑ Steel n Plastic Li Stainless Steel a Other Grout Seal Depth ✓ 0'f0 ft /Neat Cement (941b bag/5-10 gal water) El Sand Cement sack mixR gal water 171 Bentonite (20% solids) F1 Other Grout Placement Method '_ Pumped Free Fall ❑ Other [I Retardant / Accelerator (name) PEDESTAL Installed By Ll Driller El Pump Contractor F', Other r.7 Concrete Pedestal ]Dimensions: Width ft Length ft Thick in n, Christy Box -' Stove Pipe PUMP iiSubmersible❑ Turbine ❑ Other HP Pump Set ft Standing Water Level ft I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MINIMUM 48 HOUR CE OTIQIE REQUIRED FOR INSPECTIONS -PLEASE CALL (209) 953-7697 SIGNED 1 \ /�/ G�TITLE fvlanaginyEnyinear DATE 11/12/2020 T A D m w DEPARTMENT USE ONLY Application Accepted By ��CJ � Date /} J:. � Area L� Employee ID# ! �"� Grout Inspection By Date 1 SPECIAL Well Permit Pump Inspection By Date � I WAIVER Received Soil Boring Inspection By Date (il /1 �L�w Constructed Well Depth irCD . ft HO 43-06 revised 4/14/18 WELL /PUMP PERMIT I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MINIMUM 48 HOUR CE OTIQIE REQUIRED FOR INSPECTIONS -PLEASE CALL (209) 953-7697 SIGNED 1 \ /�/ G�TITLE fvlanaginyEnyinear DATE 11/12/2020 T A D m w DEPARTMENT USE ONLY Application Accepted By ��CJ � Date /} J:. � Area L� Employee ID# ! �"� Grout Inspection By Date 1 SPECIAL Well Permit Pump Inspection By Date � I WAIVER Received Soil Boring Inspection By Date (il /1 �L�w Constructed Well Depth irCD . ft HO 43-06 revised 4/14/18 WELL /PUMP PERMIT 4/14/18 WELL /PUMP PERMIT