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D <br />WELL/PUMP PERMIT 15 <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 565 <br />W. Clover Road CITY/ZIP pTracy, California <br />CROSS STREETy r APN 214 -210 -OV PARCEL SIZE 1 , l f LAND USE APPLICATION # <br />OWNER NAME Skyline Hospitality Inc. Imchaminaa Z ijwr PHONE 559-289-7314 <br />OWNER ADDRESS <br />39356 N. Owl Perch Ct /-7j-D Br 1 ak iZtJC(['Vr /STATE/ZIP Sanger, CA 93657 r� /Pt7 C) d CH <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/STATE/ZIP <br />LICENSE / C-57 C-61 D-09 Other NUMBER 499908 EXPIRATION DATE 10/31/2018 <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section <br />NTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System <br />If different from Owner Water bySt8M Name Contact Name or Phone N=ber <br />TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br />Monitoring Wells) # of wells Soil Boring # of borings s) Geotechnical 5 A of borings <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair -TilT5UFeet) <br />Kalse wen <br />Drilling Method Mud Rotary t Air Rotary VAuger Cable Tool Push Point Other <br />Proposed Well Depth 1 p -50 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 4% in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br />Grout Seal Depth / V t - ft .Neal Cement (94 /b bag/5-10 gal water) Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method Pumped Free Fall xOtherEM( 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 ft Standing Water Level ft <br />R�-1V 41,�I <br />SUN�1 VFD <br />wQgQ�B� ?018 <br />/ '0 N C <br />Tye r'" M.4 r <br />T <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 />ANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />TITLE Managing Engineer DATE- 06/04/2018 <br />EPA TMENT USE N Y <br />Application Accepted ByAYJAKDate <br />Grout Inspection By Date <br />Pump Inspection By i Date <br />Soil Boring Inspection ByV Date <br />COMMENTS <br />Area �3 Ob Employee ID#_ <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth ft <br />U_1 <br />D <br />0 <br />m <br />N <br />, 53V <br />PE SC Received <br />Codes Info By <br />Chec <br />ash <br />Amount Date <br />Remitted <br />Permit/ <br />Service Request # <br />Invoice # Well ID# <br />z7 9- <br />W 1Y 14 <br />if 0 0 361-'W <br />EH D 43-06 WELL/PUMP PERMIT <br />4/30112 <br />EIVED <br />0 5 2018 <br />TAL HEALTH <br />:RVICES <br />