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L <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 GALL (2U9) 953-1691 FOR INSPECTIONS t7LY1Kt5 l TEAR FROM UA It 155UEU <br />JOB ADDRESS 21681 Oleander Avenue CITYIZIP Manteca. CA <br />CROSS STREET Fig Road APN _V 4111PARCEL <br />SIZE LAND USE APPLICATION # <br />OWNER NAME .lames Rogers /� PHONE <br />OWNER ADDRESS 21681 Oleander Avenue / 7/ 36�N V CITYISTATE/LP Manteca. CA <br />CONTRACTOR Krazan 8 Associates. Inc. PHONE 559.348.2200 <br />CONTRACTOR ADDRESS 215 W. Dakota Avenue <br />SUBCONTRACTOR Krazan & Associates. Inc <br />SUBCONTRACTOR ADDRESS 215 W. Dakota Avenue <br />LICENSE C-57 C-61 D-09 Other <br />CITY/STATE/ZIP Clovis, California 93612 <br />PHONE 559.348.2200 <br />CITYISTATE/ZIP Clovis, California 93612 <br />NUMBER 499908 ExPIRATION DATE 10 31 .2018 <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE i I Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br />'I Public Water System <br />11diHerent from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK .1 New Well Replacement Well Well Alteration/Modification Other <br />n Monitoring Well(s) # of wells Soil Bonng(s) p of benogs Geotechnical # of borings <br />'.I Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair ­T5117a tl <br />WELL CONSTRUCTION <br />Drilling Method Mud Rotary Air Rotary . ` Auger Cable Tool Push Point Other <br />Proposed Well Depth ft Excavation in diameter Open Bottom ❑ Gravel Pack/Gravel Size in diametE <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched Steel I Plastic Stainless Steel Other <br />Grout Seal Depth ft V Neat Cement (94 Ib bag/5-10 gal water) LI Sand Cement sack mixl7 gal WatE <br />Bentonite (20% solids) Other <br />Grout Placement Method Pumped I] Free Fall Other Retardant/Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor Other <br />Concrete Pedestal -]Dimensions: Width It 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 />MINIMUM 4/88 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 9 3-7 97 (x+ <br />SIGNED TITLE Manaclinci EnninePr DATE �' <br />1 A R MENT S E <br />Application Accepted By tJ ate Area Employee ID#� <br />Grout Inspection By Date l � PECIAL WGil Permit <br />Pump Inspection By Dale WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />EHD 43-M revised 4/14118 / /1/1.ez-1, / X39. dv/ Xy )A'5/ WELL /PUMP PERMIT <br />