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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 />1'IVIY-Mitt-UNDAULt I-LKMI I t ALL jZU%1j `19.73-1011 [-UK INSYtG IIUN5 GAYIKGJ l T tAK I-KUM IJATE I5SUE1 <br />JOB ADDRESS 5999 Escalon Bellota Road CITY/ZIP Linden CA <br />CROSS STREET Escalon Bel ola Road APN0g3 PARCEL SIZI?45— LAND USE APPLICATION # <br />OWNER NAME Foster Farms l� PHONE 209-398-6716 <br />OWNER ADDRESS 14519 W. Collier Road / A &V�e 4� 7 CITY/STATE/ZIP Delhi, CA 95315 <br />CONTRACTOR Krazan & Associates, Inc PHONE 559 348 2200 <br />CONTRACTOR ADDRESS 215 W Dakota Avenue <br />SUBCONTRACTOR Krazan & Associates, Inc <br />SUBCONTRACTOR ADDRESS 215 W Dakota Avenue <br />LICENSE / C-57 C-61 D-09 Other <br />CITY/STATE/ZIP Clovis, California 93612 <br />PHONE 559.3482200 <br />CITY/STATE/ZIP Clovis, California 9361; <br />yy4l)H <br />NUMBER EXPIRATION DATE <br />1031 2020 <br />DOMESTIC WELL SAMPLING: - General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE 0 Domestic/Private Irrigation/Ag6cultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br />❑ Public Water System <br />Ifdifferent from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK in New Well Replacement Well Well Alteration/Modification Other <br />Monitoring Well(s) # of wells Soil Boring(s) # of bonngs Geotechnical 2 • of bodngs <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair T277eetI <br />New Pump u Pump Replacement Pump Repair Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method D Mud Rotary , D Air Rotary y` Auger Cable Tool Push Point Other <br />Proposed Well Depth SG ft Excavation in diameter Open Bottom -1 Gravel Pack/Gravel Size in diarf&j <br />Conductor Casing in diameter / Conductor Casing Depth ft H F <br />Well Casing Diameter fn Thickness/Gauge/ASTM Schad Steel I] Plastic Stainless Steel Other FA <br />Grout Seal Depth4!T, ft ,/ Neal Cement (94 Ib bag/5-10 gal water) I i Send Cement sack mixf7 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method Pumped a Free Fall Other Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller D Pump Contractor Other <br />Concrete Pedestal []Dimensions: Width It Length ft Thick in Christy Box Stove Pipe <br />PUMP Submersible Turbine i7 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 />VE PTMENT U E O LY <br />Application Accepted By , to �/ Area Employee ID# <br />Grout Inspection Date PECIAL Well Permit <br />Pump Inspection B i Date WAIVER Received <br />Soil Boring Inspection Date Constructed Well Depth ft <br />COMMENTS <br />N <br />m <br />D <br />0 <br />°a <br />m <br />N <br />�al f <br />EHD 43-06 revised 4/14/18 WELL /PUMP PERMIT <br />