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A <br />RECEIVED <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468AY 2 3 2018 <br />NON-REFUNDABLE PERMIT ALL 209) 953- 697 F N ECTIONS EXPIRES 1 YEAR FROM DATE ISSUED u <br />rA <br />JOB ADDRESS SEC of River Island Parkway & Golden Valley Parkway CITY/ZIP Lathrop, California 1 R0N NTAL FI EALT11 <br />DE11 TNIENT <br />y — � rq�'��U ��P S AND USE APPLICATION # <br />CROSS STREET APN ARCEL IZE m <br />OWNER NAME In N Out Burger �E (J�Q�1��1q'�NE 626-813-8275 y <br />OWNER ADDRESS 13502 Hamburger Lane CITY/STATE/ZIP 881�WIr1 Park, CA 91706 <br />CONTRACTOR Krazan & Associates, Inc. PHONE 559.348.2200 <br />CONTRACTOR ADDRESS 215 W. Dakota Avenue <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />C-57 C-61 D-09 Other <br />CIN/STATE/ZIP Clovis, CA 93612 <br />CITYISTATE/ZIP <br />NUMBER 499908 <br />PHONE <br />EXPIRATION DATE 10/31/2018 <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br />INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System <br />If different from Owner: Water 5YStem Name ontaCt Name or Phone Number <br />TYPE OF WORK New Well Replacement Well Well Mteration/Modification Other <br />Monitoring Well(s) # of Wells Soil Boring(s) # of bonngs Geotechnicai 6 If of borings <br />-TfU 5U <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repairreet) <br />Drilling Method Mud Rotary r Air Rotary Auger Cable Tool Push Point Other <br />Proposed Well Depth/0 ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter T-, �ina Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br />Grout Seal Depth fO7 Cft -/ Neat Cement (94 Ib bag/5-10 gal water) Sand Cement sack mixf7 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method Pumped Free Fall Other 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 />PUMP Submersible Turbine Other 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 I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />MINIM M 24 H A VANCE NOTICE UIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />Q.'-.r:r, -L- TITLE Managing Engineer DATE 05/22/2018 <br />pq)41A <br />N <br />>aMFNpUN�Y <br />ll A�LD <br />NTU E NdYApplication Accepted By Vte Area I nployee ID# <br />of Grout Inspection By Date __ _ SPECIAL Well Permit <br />Pump Inspection By Date WAIVER Received <br />Soil Boring Inspection By Date .l ! � — Constructed Well Depth It <br />COMMENTS <br />PE SC <br />Codes Info <br />Received hec <br />B ash <br />Amount Date Permltl Invoice # Well ID# <br />Remitted Seryice Re uest# <br />',) 3 <br />EHD 43-06 <br />4130/12 <br />