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WELL/PUMP PERMIT f / 0 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />REFUNDABLE PERMIT GALL (ZUV) VbJ-1697 FOR INSPECTIONS tArllltS 'I T LAK I-KUM UAIt IJSUtU <br />9 d / <br />1DRESS SEC of W. Harding Way and Madison Avenue hqo (/j fnC'MP Stockton, CA Ca, p jl <br />STREET N Commerce Street APN /37 5) PA EL SIZE r' I LAND USE APPLICATION If <br />NAME DiabDiabEnterprises /�rouK 4 c5ah1rCL 1.71T�,GYC�hira L7�� PHONE 209.601.9132 <br />ADDRESS 5950 North Highway 99 Ili*pre pak,,w)de Ave CITY/STATE/ZIP Stockton, CA 95212 <br />ACTOR Krazan & Associates, Inc. PHONE 559.348.2200 <br />ADDRESS 215 W. Dakota Avenue <br />CITY/STATE21P Clovis, CA 93612 <br />SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br />LICENSE . C-57 C-61 D-09 Other NUMBER 499908 <br />PHONE <br />ExPIRAnoN DATE 10/31/2018 <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br />NTENDED USE Domestic/Private Irrigation/Agricultural Industrial `t Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System <br />If different from Owner: Water System Nam L;ontaCt Name or one um r <br />TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br />Monitoring Well(s) # of wells " Soil Boring(s) r of borings ►Geotechnical 5 It of borings <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair ( /O <br />_ New rum i-ump Ke iacement - rump Ke au Karse vven L asn <br />WELL CONSTRUCTION <br />Drilling Method Mud Rotary Air Rotary VAuger Cable Tool Push Point Other <br />Proposed Well Depth It Excavation in diameter I IOpen Bottom Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter412 in Thickness/Gauge/ASTM Schad Steel Plastic Stainless Steel Other <br />Grout Seal Depth ft f Neat Cement (941b bag/5-10 gal water) Sand Cement sack mixl7 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method Pumped Free Fall Other Retardant / Accelerator (name) <br />PEDESTAL Installed By 'Driller Pump ConVactor Other <br />Concrete Pedestal ,Dimensions: Width ft Length ft Thidt in Christy Box Stove Pipe <br />Puma 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 />C--MTl*NWL A 24 HOVR'ADiVANtE NOT�REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Ins%iry� By <br />COMMENTS i/ I�r , <br />�e Managing Engineer DATE 04/16/2018 <br />rn <br />D <br />0 <br />m <br />PA <br />IS66'v 10 <br />LIZO <br />)R 112018 <br />�ON�F %Airy <br />DFpgR MENT <br />P TMEN T US O LY <br />Date Area 00110-1 Employee ID#�� <br />Date '(7 SPECIAL Well Permit <br />Date WZ111 it WAIVER Received <br />Date Constiucled Well Depth ft <br />n / 1i <br />PE SC ReceivedChec <br />Codes Info B s <br />Amount PenniV <br />emitted Date Service Request # Invoice # Well IDM <br />19 <br />u3 ( 57 <br />EMD 43-M <br />4131/12 <br />WELL (PUMP PEHMI I <br />