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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 /> JOB ADDRESS <br /> 8892 S.Van Allen Road CITY/ZIP Escalon,CA T <br /> ,-'�,f/ <br /> CROSS STREET G.(FSYY/V ri APN 185-110-05 PARCEL SIZEN. AND USE APPLICATION# v <br /> m <br /> OWNER NAME Borges Dairy PHONE H <br /> OWNER ADDRESS 8892 S.Van Allen Road CITY/STATE/ZIP Escalon,CA �4�Qt�ron/ <br /> CONTRACTOR Krazan&Associates,Inc. PHONE 559.348.2200 <br /> CONTRACTOR ADDRESS 215 W.Dakota Avenue CITY/STATE/ZIP Clovis,California 93612 <br /> SUBCONTRACTOR Krazan&Associates,Inc. PHONE 559.348.2200 <br /> SUBCONTRACTOR ADDRESS 215 W.Dakota Avenue CITY/STATE/ZJP Clovis,Califomia 93612 <br /> LICENSE VC-57 C-61 i,D-09 Other NUMBER 499908 EXPIRATION DATE 10/31/2020 <br /> DOMEsTic WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) 1 Arsenic(4393) <br /> INTENDED USE DomesticfPrivale 1 Irrigation/Agricultural Industrial i Water Quality Monitoring ! Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification i Other <br /> Monitoring Well(s) #of wells Soil Bodng(s) #of borings rl Geotechnical 3 #of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal i Cross-Connection Repair (15-50 Feet) <br /> New Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method 1 Mud Rotary Air Rotary /Auger Cable Tool Push Point Other <br /> Proposed Well Depth y-Iqtft Excavation in diameter 1 i Open Bottom Gravel Pack/Gravel Size in diameter <br /> I 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 ft�-5u, It */Neat Cement(94 Ib bag/5-10 gal water) Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method !!Pumped iFree Fall Y Other196A 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 Submersible Turbine 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 /> M 48 H V E NOTIC QUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGN TITLE Managing Engineer DATE 01/03/2020 <br /> RF YMFNT <br /> C�jV�D <br /> IAA( <br /> V/RoNIN co <br /> E„Q RTMENT <br /> Application Accepted By�F7r�/1`J Dale Area Employee ID# � <br /> Grout Inspection By Date I I SPECIAL Well Permit <br /> Pump Inspection By Date I WAIVER Received <br /> Soil Boring Inspection By Date V! / G L/ LJ) Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received hec Amount at Permit/ Invoice# Well ID# <br /> Codes Info Remitted Service Re uest# <br /> EHD 43-06 revised 4/14/18 WELL/PUMP PERMIT <br />