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WELL/PUMP <br />Drilling Method <br />PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />Proposed Well <br />Depth ,n"0'-:�J It Excavation <br />1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />PERMIT <br />ADDRESS 2040 McHenry Avenue <br />CALL (209) 953-7697 FOR INSPECTIONS EXPIRES <br />CIiY/ZIP Escalon, CA <br />CROSS STREET U I r e V APN Or PARCEL SIZE Zy"I LAND USE APPLICATION <br />OWNER NAME City of Escalon PHONE <br />OWNER ADDRESS 2060 McHenry Avenue <br />CONTRACTOR <br />Krazan &Associates,lnc. <br />CONTRACTOR ADDRESS 215 W. Dakota Avenue <br />SUBCONTRACTOR Krazan &Associates, Inc. <br />SUBCONTRACTOR ADDRESS 2.15 W Dakota Avenue <br />CITY/STATEMIP Escalon, CA <br />PHONE 5'9.348.2200 <br />CITYISTATEIZIP �'IOVIS, California 93612 <br />PHONE 559.348.2200 <br />CITYISTATE/ZIP Clovis, California 93012 <br />(LICENSE VJC-57 D C-61 ❑ 0-09 ❑ Other. NUMBER 499908 EXPIRATION DATE 10.31.202.1 <br />DOMESTIC WELL SAMPLING: 0 General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) L7 Arsenic (4393) <br />INTENDED USE Li Domestic/Private D Irrigation/Agricultural [I Industrial 11 Water Quality Monitoring El Soil <br />Sampling/Characterization <br />D Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK ❑New Well 11 Replacement <br />Well <br />❑ Well Alteration/Modification D Other <br />D Monitoring Wells) # of wells <br />D Out -Of -Service Well <br />F1 NPw Pumn n Pumn Renlarpmenf <br />11 <br />Li <br />#of borings Geotechnical 2 #of borings <br />❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair (20-50 Feet) <br />F1 Pumn Renair D Raise Well Casino <br />WELL CONSTRUCTION <br />Drilling Method <br />❑ Mud Rotary D Air Rotary V Auger D <br />Cable Tool D Push Point ❑ Other <br />Proposed Well <br />Depth ,n"0'-:�J It Excavation <br />in diameter D Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br />❑ Conductor Casing in diameter / <br />Conductor Casing Depth It <br />Well Casing <br />Diameter_ in Thickness/Gauge/ASTM Sched D Steel D Plastic D Stainless Steel ❑ Other <br />Grout Seal <br />Depth .ZO A-2;70 ft /(Neat Cement (94 <br />Ib bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br />D Bentonite (20% solids) D Other <br />Grout Placement <br />Method D Pumped ❑ Free Fall D Other <br />D Retardant / Accelerator (name) <br />PEDESTAL <br />Installed By D Driller D Pump Contractor <br />❑ Other <br />❑ Concrete Pedestal ❑Dimensions: Width <br />It Length It Thick in ❑ Christy Box ❑ Stove Pipe <br />PUMP <br />D SubmersibleD Turbine ❑ Other. <br />HP Pump 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 1 AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />MINIMUM OURAmVA E REQUIRED <br />FOR INSPECTIONS -PLEASE CALL (209) 953-7697 <br />SIGNED � TITLE Managing Engineer DATE 11/12/2020 <br />DEPARTMENT USE ONLY <br />Application Accepted By � �L.-- Date .� O.�a <br />Grout Inspection By Date <br />Pump Inspection By Date <br />Soil Baring Inspection <br />�By Dale <br />COMMENTS Vii};MMERWTE <br />id <br />Area -T SIG 1.�, Employee ID# !r`i C'r <br />❑ SPECIAL Well Permit <br />1:1 WAIVER Received <br />Ih`�II <br />:r< <br />� CFjV �T <br />V <br />EHO 43-06 revised 4/14/18 <br />WELL /PUMP PERMIT <br />