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WELL/PUMP PERMIT PI ' <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 1880 Daniels Street CITY/ZIP Manteca, California 9'5337 <br />CROSS STREET �tJ � la o I A 1, p /ly APN 9 O( ,[ J V PARCEL SIZE �' LAND USE APPLICATION # <br />OWNER NAME Avtar Dhillon / 34c, Am ni Ce✓ ar fe,`yyy+ tL 1-C PHONE <br />OWNER ADDRESS 9950 Koa Lane /1 q /0 3 M� r CITY/$TATE/ZIP Elk Grove, CA 95624 ma <br />CONTRACTOR Krazan & Associates, Inc. ' _ 1 PHONE 559.348.2200 <br />CONTRACTOR ADDRESS 215 W. Dakota Avenue CITY/STATE/ZIP Clovis, CA 93612 <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br />LICENSE f 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: a er system Name -------C-o-nTaff Name or Ptione Number <br />TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br />MonitoringWell(s) #of wells SoilBoring(s) #of borings Geotechnical 5 #orborinps <br />Out -Of -Service Well Out -Of -Service Weil Renewal Cross -Connection Repair (1-50Feat) <br />Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br />Proposed Well Depth It Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter412 in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br />Grout Seal Depth ft V Neat Cement (94 Ib bag/5-10 gal water) Sand Cement sack mixR gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method Pumped Free Fall Other rimmle 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 R <br />I HEREBY CERTIFY THAT 1 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 COMPENSATI AWS. <br />I'llM H D 40TICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 S ,/ <br />SIG TITLE Managii5Engineer DATE 06/25/2018 h�lC/�/A. <br />rn <br />D <br />0 <br />°z <br />N <br />��331, <br />ECEIVED <br />UIQ 2 0" 20=18 <br />!AL HEALTH <br />PARTMENT USE%ONyIL A <br />Application Accepted By Date 16 - /U Area � I �C1 A Employee ID# Ah rr1 P U' <br />Grout Inspection By Date SPECIAL Well Permit <br />Pump Inspection By Date WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />PE <br />Codes <br />SC <br />Info <br />Received Ch <br />B as <br />Amount <br />Remitted <br />Date Permit/ Invoice # Well ID# <br />Service Re nest # <br />9371 <br />ISS <br />33351 <br />39 <br />W 663j5g1 g--A- <br />EHD 43-06 WELL /PUMP PERMIT <br />4/30/12 <br />