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TMENT U E NLY <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS L/6....A.C..A.A60 or'r 0'1 10 <br />—5-ee—ccry9.6-* <br />4 <br />Date <br />Date <br />Date <br />Date <br />of. 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.s ov.or /ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 17597 Beeler Road cirvizip Escalon 95320 <br />CROSS STREET Highway 120 ApN 229-030-230-000 PARCEL SIZE 1939. Acres LAND USE APPLICATION # <br />OWNER NAME Daniel & Lori Gust PHONE (209) 601-3712 <br />OWNER ADDRESS 17597 Beeler Road cry/sum/zip Escalon 95320 <br />CONTRACTOR PHONE <br />CONTRACTOR ADDRESS CITY/STATE/ZIP <br />SUBCONTRACTOR/CONSULTANT PHONE <br />SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP <br />LICENSE _ C-57 C-61 D-09 _ Other NUMBER EXPIRATION DATE <br />BILLING PARTY: OWNER - CONTRACTOR Ll SUBCONTRACTOR/CONSULTANT <br />Domss-ric WELL SAMPLING: General Mineral/Coliform Bacteria (4391) i_ Dibromochloropropane (4392) Arsenic (4393) P <br />INTENDED USE Domestic/Private Irrigation/Agricultural Industrial El Water Quality Monitoring E Soil Sampling/Characterization <br />Public Water System RI <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 />SC <br />Monitoring Well(s) # of wells . Soil Boring(s) # of borings = Geotechnical C ot borings , <br />X Out-Of-Sentice Well : Out-Of-Service Well Renewal - Cross-Connection Repair <br />SAN JOA _ New Pump i Pump Replacement Pump Repair Raise Well Casing <br />ENV/H WELL CONSTRUCTION HEAL-T.14. <br />Drilling Method 1 Mud Rotary L Air Rotary I Auger u Cable Tool E Push Point , ' Other <br />Proposed Well Depth ft Excavation in diameter II Open Bottom Gravel Pack/Gravel Size in diameter <br />ii Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched -i Steel i - Plastic L Stainless Steel i Other <br />Grout Seal Depth ft - Neat Cement (94 lb bag/5-10 gal water) Sand Cement sack mix/7 gal water <br />Li Bentonite (20% solids) _ Other <br />Grout Placement Method _ Pumped _ Free Fall E Other i Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller.7 Pump Contractor Other <br />: Concrete Pedestal :Dimensions: VVidth ft Length ft Thick in i Christy Box 1 Stove Pipe <br />PUMP Submersible Turbine I Other HP Pump Set ft Standing Water Level ft <br />YME Aiver , <br />CEIvED <br />09 2019 <br />QUIN CIDNs' ONMENTAUL T <br />.IDARTAIEN7 , <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 />MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED Z-744.4ai rist DATE 8/28/19 TITLE Owner <br /> <br />Areocier <br /> <br />i <br />P <br />Area Ct 4 1 Employee ID# 4115.9144516414 <br />ECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth <br />fRtipilt4 — , V77)771960 f4 <br />PE <br />Codes <br />SC <br />Info <br />Received Checke/ Amount Date Permit/ <br />Service Re uest # Invoice # Well 104 <br />'1 i <br />ee, #4574;szher4mitted ,72-eJ/fr/jq 1,11 4- ? <br />EHD 43-06 6/11/2019 <br />aw/ .75-15L.3 <br /> WELL /PUMP PERMIT