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el <br />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 6515 Inglewood Avenue e* j t/, /�1 CITYIZIP Stockton, CA 95207 <br />CROSS STREET Benjamin Holt Drive APN O V 1 i1 ` Vy 5 4 PARCEL SI�Z+E��I' "� LAND USE APPLICATION # <br />OWNER NAME �,,r,,.?Abble Charter Schools / t4umphref a S G�� I FiiP _ ��� PHONE 209.478.1600 <br />OWNER ADDREs�s 9;; Inglewood Avenue CITY/STATE/ZIP Stockton, CA 95207 <br />CONTRACTOR Krazan & Associates, Inc. PHONE 559.348.2200 <br />CONTRACTOR ADDRESS 215 W. Dakota Avenue CITY/STATEIZIP Clovis, CA 93612 <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS CITY/STATEIZIP <br />LICENSE / C-57 C-61 '._.D-09 Other NUMBER 499908 E%PIRATION DATE 10/31/2018 <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section <br />WENDED USE " DomesticlPrlvate `* Irrigation/Agricultural :" . Industrial Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System <br />If different from Owner: water UyStern Nam Contact Nam or Plhone Number <br />TYPE OF WORK New Well Replacement Well Well Alteration/Modification :. Other <br />Monitoring Well(s) # of wells 'Soil Boring # Of borings s) 4 # of borings Geotechnical ` <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />New Pumo :'. Pumo Reolacement Pumo Reoair Raise Well Casino `I <br />Drilling Method " Mud Rotary Air Rotary Auger '? Cable Tool � Push Point Other <br />Proposed Well Depth 1U -So ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br />Conductor Cas' g in diameter / Conductor Casing Depth ft <br />Well Casing Diameter <br />Conductor <br />Sched Steel Plastic Stainless Steel Other _ <br />Grout Seal Depth 10-50 ft f Neat Cement (94 /b baV5-10 gal water) Sand Cement sack mix17 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method Limped Free Fall Other Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor Other <br />Concrete Pedestal ...Dimensions: Width ft Length It Thick in Christy Box : Stove Pipe <br />PUMP Submersible Turbine ::' Other HP Pump Set ft Standing Water Level It <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 />MINIMUM '124,HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED TITLE Managing Engineer DATE 10/18/2016 <br />�I <br />b <br />O <br />m <br />w <br />DEPARTMENT USE ONLY < <br />Application Accepted By Date -0 Area S� Khmployee ID# <br />Grout Inspection By Date -D SPECIAL Well Permit / <br />Pump Inspection By Date t7 WAIVE Received <br />Soil Boring Inspect'o By Date Cons cte I ell Depth ft <br />COMMENTS . a__- _ GAS S n q Int IC w ! • [ ti ' <br />PE <br />Codes <br />SC <br />Info <br />Received Check#! <br />B Cash <br />Amount <br />Remitted Date <br />Permit <br />Service Regoast# Invoice# Well ID# <br />4D <br />IS <br />_ <br />330.230 <br />IJP 06 y <br />EHD 43-06 WELL /PUMP PERMIT <br />4130112 <br />