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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUND^o'e:DiE�RMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Joe ADDRESS - "1 -.,•� [ jG� i Ln <br /> CITr21P Stockton C' m <br /> / 5 10 <br /> CROSS STREET Munsford AvenueApt � �tl�J ✓,i PARCEL SIZE 2D 79 LAND USE APPLICATION# z <br /> OWNER NAME Associated Engineering Group 209.545.3390 H <br /> PHONE <br /> OWNER ADDRESS 4206 Technology Way Suite 4 CITY/STATi Modesto,California 95356 <br /> CONTRACTOR Krazan&Associates,Inc. PHONE 559.348.2200 <br /> CONTRACTOR ADDRESS 215 W.Dakota Avenue CITYISTATEJZIP Clovis,CA 93612 <br /> SUBCONTRACTOR Krazan&Associates,Inc. PHONE 559.348.2200 <br /> SUBCONTRACTOR ADDRESS 215 W.Dakota Avenue CITY/STATEIZIP Clovis,CA 93612 <br /> LICENSE X C-57 C-01 D-09 Other NUMBER 499908 EXPIRATION DATE 10/31/2016 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Rari Section_ <br /> INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner Water by5tern Name on a ame or Phone um er <br /> TYPE OF*WORK New Well ' Replacement Well Well AlterationlModificatlon Other <br /> Monitoring Well(s) #of wells Soil Borin s #W borina s <br /> 9O Geotechnical 1 #orbodnps <br /> Out-Of-Service Well I OUt-Of-Service Well Renewal Cross-Co nection Repair <br /> New Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotaly Air Rotary X Auger Cable Tool Push Point Other <br /> Proposed Well Depth ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter I Conductor Casing Depth a 'ti <br /> Well Casing Diameter_in .Thickness/Gauge/ASTM Sched St I s eel t <br /> Grout Seal Depth ft �leat Cement(94/b bagr5-10 gal water) C ix! I <br /> wk4iD <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped Free Fall Other Retard f t r JaIIli Pi7rurAd wit, I t <br /> PEDESTAL Installed By Driller Pump Contractor Other mod'ad <br /> Concrete Pedestal Dimensions:Width ft Length ft. <br /> 09 COM*Wd <br /> t. <br /> PUMP Submersible Turbine Other HP Pump 6W - tl vwRwfAtW4r=mtn <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN 11 <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 /> MINIM OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE Managing Engineer DATE 05/28/2015 <br /> 1 � <br /> v <br /> Uy 25 7.O i5 <br /> w. <br /> I IV ol 410 <br /> LLJ <br /> EI I `i/ E® <br /> # --LO& L 28 2015 <br /> E--L FT-=-- <br /> DEPARTMENT USE ONLY EWRONMENTAL HEALTH <br /> Application Accepted By Date .l l 1 Area �' I Employee ID# PERMIT/SERVICES <br /> Grout Inspection By Date ['1 S ECTAL Well Permit k-�7�G�j' Y:-7 <br /> Pump Inspection By Date U WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received e_C_k#1. Amount Permi" <br /> Codes Info EI Cash Remitted- Date Service Re uest# Invoice# Well ID# <br /> 31Rg1 <br /> F- <br /> EHD 4106 <br /> 4.00112 WELLIPUMP PERMIT <br />