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4 <br />WELL/PUMP PERMIT ` V <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN-KEFUNDABLE PERMIT <br />CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 25499 East Flood Road <br />Jgg9 <br />N `i�- I 116ZIAP Linden, CA 9> <br />CROSS STREET Escalon Bellota Road <br />APIN <br />27 2(/ <br />/ 0 PARCEL SIZE / / + LAND USE APPLICATION # <br />OWNER NAME Foster Farms Z 6;� <br />'-t' <br />L L C, PHONE 209398-6716 <br />OWNER ADDRESS 14519 W. Collier Road <br />�O SQX�T <br />CITY/STATE/ZIP Delhi, CA 95315 ��/�� j -r <br />CONTRACTOR Krazan & Associates, Inc. <br />PHONE 559.348.2200 <br />CONTRACTOR ADDRESS 215 W. Dakota Avenue <br />CITY/STATE/ZIP Clovis, California 93612 <br />SUBCONTRACTOR Krazan & Associates, Inc. <br />SUBCONTRACTOR ADDRESS 21' W. Dakota Avenue. <br />LICENSE '/C-57_ C-61 D-09 Other <br />PHONE 559.348.2200 <br />CITY/STATE/ZIP Clovis. California 93612 <br />NUMBER 4999014 EXPIRATION DATE 10.31.2018 <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) I , Arsenic (4393) <br />WENDED USE n Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Sail Sampling/Characterization <br />u Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK ❑ New Well I Replacement Well ❑ Well Alteration/Modification I Other <br />1_1 MonitoringWell(s) #of wells ❑ Soil Boring(s) 0ofborings Geotechnical 1 #of borings <br />I Out -Of -Service Well I. Out -Of -Service Well Renewal Cross -Connection Repair ' eetj <br />!I New Pumo ❑ PumD Replacement PumD Reoair Raise Well Casino <br />Drilling Method i 1 Mud Rotary U Air Rotary / Auger Cable Tool Push Point Other <br />Proposed Well Depth ft Excavation in diameter I i Open Bottom Gravel Pack/Gravel Size in diameter <br />I Conductor Casing in diameter / Conductor Casing Depth It <br />Well Casing Diameter �A Thickness/Gauge/ASTM Sched 17 Steel I Plastic I Stainless Steel Other <br />Grout Seal Depth i7 S. ft ;j Neat Cement (94 lb bag15-10 gal water) Sand Cement sack mix/7 gal water <br />ll Bentonite (20% solids) Other <br />Grout Placement Method Pumped C Free Fall Other-a-Ud& Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor Other <br />Concrete Pedestal (Dimensions: Width It Length It Thick in Christy Box Stove Pipe <br />PUMP Submersibles Turbine :I Other HP Pump Set ft 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 />NT USE O L (�y,�/J/_ <br />Application Accepted By Date C� Area Employee ID#j' <br />Grout Inspectio Date SPECIAL Well Permit <br />Pump InspectDi y Date WAIVER Received <br />Soil Boring Inspe:V Date Constructed Well Depth It <br />COMMENTS <br />PE Sc Received Check#/ Amount Perm! U <br />Codes Info B Cash emitted Date Service Re uest # Invoice # Well ID# <br />33L4 <br />EHD 43-06 revised 4114118 WELL /PUMP PERMIT <br />A <br />