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PAX <br />0 WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENU <br />NUN-KEFUNDABLE PERMIT 1 <br />1120 Frewert Road <br />JOB ADDRESS <br />CROSS STREET S. Manthey Road <br />IER NAME Harvest Power <br />IER ADDRESS 6943 N Golden State Blvd. <br />TRACTOR Cal PaC Drilling <br />TRACTOR ADDRESS 526 W. Ave. L <br />-TOR ADDRESS <br />�( C-57 <br />C-61 D-09 <br />• <br />C95 <br />E -STOAO.) NNED <br />.ALL LUt7 V* i-1OV f FUK IN,I'LL; IIVNJ CArIRC.7 l i CHK tKUM YA I G IJJUCu <br />CITY/ZIPLathrop, CA 95330 <br />APN 191-270-05 PARCEL SIZE 20 Acres LAND USE APPLICATION # <br />PHONE <br />CITY/STATE/ZIP Fresno, CA 93722 <br />PHONE 909-795-7500 <br />CITY/STATE/ZIP Calimesa, CA 92320 <br />PHONE <br />CITY/STATE/ZIP <br />Other NUMBER 766402 <br />EXPIRATION DATE 07/31/2017 <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township _ Range Section_ <br />INTENDED USE Domestic/Private Irrigation/Agricultural Industrial AWater pt y Monitoring Soil Sampling/Characterization <br />Public Water System VA Daya Bettadapura, PE, Ph.:(949)510-8874 <br />If different from Owner: Water system Name COhtaCt Name or Phone um <br />TYPE OF WORK XNew Well Replacement Well Well AReration/Modification Other <br />)(MonitoringWell(s) 2 #of wells SoilBodng(S) #ofborirgs Geotechnical #of borings <br />Out -Of -Service Well Out -Of -Service Well Renewal Crass -Connection Repair <br />Drilling Method Mud Rotary , Air Rotary X Auger Cable Tool Push Point Other <br />Proposed Well Depth__2K15' _ft Excavation 8„ in diameter Open Bottom XGravel Pack/Gravel Size -Sand in diameter <br />size <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter 2 in Thickness/Gauge/ASTM Schad 40 Steel X Plastic Stainless Steel Other <br />Grout Seal Depth 10 ft Neat Cement (4 jb bbag�l5-10 gal water Sand Cement sack mixt] gal water <br />X Bentonite (20% solids) Other '_ 0✓4 i <br />Grout Placement Method Pumped X Free Fall Other V Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor Other <br />Concrete Pedestal Dimensions: Width ft Length ft Thick in Christy Box Stove Pipe <br />Luum 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 />MIUM 24 HOUJ? TITLE DATE ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />Slrucn /'-? <br />'`---� I President, ABI Engineering Consultants, Inc. 8/30/2016 <br />fit" <br />SEP <br />gp,H JOAf <br />EN`n <br />R <br />NF�t-TH <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />DEPARTMENT USE ONLY <br />Gil Date Z �L <br />Date <br />Date <br />Date <br />to <br />D <br />v <br />m <br />N <br />N <br />C11111111110 <br />EVED <br />Area � EmployeeID# /e1zedtrto <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth ft <br />PE <br />SC <br />Received <br />Check#/ <br />mount Date Pertntt/ Invoice# Well 1D# <br />Codes <br />Info <br />B <br />Cash <br />�RemlttedService Request # <br />313 <br />278. S <br />EHD 4306 <br />4/30/12 <br />WELL /PUMP PERMIT <br />SCANNED <br />06 2016 <br />HEALTH <br />