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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 />Nwly-K FUNDABLE PERMIT <br />2060 McHenry Avenue <br />I:ALL IZU`J1 903-/6y/ FOR INSPECTIONS tRYlr(tJ T YtAR hRUM UAI t ISSUtU <br />CROSS STREET (film! APN <br />OWNER NAME City of Escalon <br />OWNER ADDRESS 2060 McHenry Avenue <br />CONTRACTOR Krazan & Associates, Inc. <br />CONTRACTOR ADDRESS 215 W. Dakota Avenue <br />SUBCONTRACTOR Krazan &Associates, Inc. <br />SUBCONTRACTOR ADDRESS 215 W. Dakota Avenue <br />CITU/ZIP Escalon, CA <br />PARCEL SIZE f O LAND USE APPLICATION <br />PHONE <br />CITY/STATE/ZIP Escalon, CA <br />PHONE 559.34$.2200 <br />CITY/STATEIZIP Clovis, Califomia 93612 <br />PHONE '59.348.2200 <br />CITY/STATEILP Clovis, California 93612 <br />LICENSE C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER 499908 EXPIRATION DATE 10.31.2021 <br />DOMESTIC WELL SAMPLING: � General Mineral/Coliform Bacteria (4391) � Dibromochloropropane (4392) ❑Arsenic (4393) <br />INTENDED USE ❑ Domestic/Private ❑Irrigation/Agricultural El Industrial 11 Water Quality Monitoring 11 Soil <br />Sampling/Characterization <br />E Public Water System <br />It dfferent from Cromer: Water System Name Contact Name or Phone Number <br />TYPE OF WORK 11 New Well ❑Replacement Well <br />Ll Well Alteration/Modification Li Other <br />LlMonitoring Well(s) #of wells <br />LI Out -Of -Service Well <br />n KImu, Da fl D,emn Donloromonf n <br />❑SoilBoring(s) #of boringsGeotechnical 2 #of borings <br />„ElOut-Of-Service Well Renewal ❑ Cross -Connection Repair (20-50 Feet) mPa n Rcn�ir n Raicw Wrll caslnn <br />WELL CONSTRUCTION <br />Drilling Method <br />❑ Mud Rotary ❑ Air Rotary V Auger ❑ <br />Cable Tool G Push Point <br />❑ Other <br />Proposed Well <br />Depth A' :�M it Excavation <br />in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br />❑ Conductor Casing in diameter / <br />Conductor Casing Depth <br />It <br />Well Casing <br />Diameter _ in Thickness/Gauge/ASTM Sched ❑ Steel <br />❑ Plastic D Stainless Steel a Other <br />Grout Seal <br />Depth ,rJ-J 0 it /Neat Cement (94 <br />/b bag/5-10 gal water) <br />D Sand Cement sack mix/7 gal water <br />❑ Bentonite (20% solids) E Other <br />Grout Placement Method X Pumped Pt Free Fall u Other <br />❑ Retardant/Accelerator (name) <br />PEDESTAL <br />Installed By ❑ Driller ❑ Pump Contractor <br />❑ Other <br />❑ Concrete Pedestal ClDimensions: Width <br />it Length ft <br />Thick in ❑ Christy Box ❑ Stove Pipe <br />PUMP <br />❑ Submersible❑ Turbine ❑ Other. <br />HP Pump <br />Set it 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 />DEPARTMENT USE ONLY <br />Application Accepted ey Dale �f ,� JC� Areae Employee ID# �7 <br />Grout Inspection By Date Z 6 El SPECIAL Well Permit <br />Pump Inspection By Date O WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />)MMENTS '1'C dpeot-r ihc�t�t 3U �rr 3:0 PYtLi)�1'1{N'" J r., ," ,^, O i•' Y,: , <br />Permitl <br />TOM <br />E� MENT <br />F� QED <br />V , 5 ?020 <br />QU) <br />F gRTM �NTY <br />ENT <br />EHD 43-06 revised 4H4/18 WELL /PUMP PERMIT <br />