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• WELL/PUMP PERMIT <br /> r 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 /> 1240 Navy Drive 7 CITYIAP Stockton.California m <br /> JOB ADDRESS N y ` l Lz <br /> CROSS STREET APN y 0- O— ` 7 PARCEL SIZE 5.1PLAND USE APPLICATIONIN <br /> # p <br /> OWNER NAME Tru Star Energy LLC PHONE !r! <br /> OWNER ADDRESS 1 North Lexington Avenue �� � CITY/STATE/LP White PIanS,NY 10601 <br /> CONTRACTOR <br /> Krazan&Associates,Inc. PHONE 559.348.2200 <br /> CONTRACTOR ADDRESS 215W Dakota Avenue CITY/STATE/ZIP Clovis,California 93612 <br /> SUBCONTRACTOR <br /> Krazan&Associates,Inc. PHONE 559.348.2200 <br /> SUBCONTRACTOR ADDRESS 215 W.Dakota Avenue CITY/STATE/ZIP Clovis.California 93612 <br /> LICENSE VC-57 I I C-61 Ii D-09 I I Other NUMBER 499408 EXPIRATION DATE 10'31 2018 <br /> DOMESTIC WELL SAMPLING:!7 General Mineral/Coliform Bacteria(4391)C Dibromochloropropane(4392)C Arsenic(4393) <br /> INTENDED USE I Domestic/Private I-Irrigation/Agricultural 11 Industrial I Water Quality Monitoring I'Soil Sampling/Characterization <br /> I Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK I.I New Well .!Replacement Well CC,Well Alteration/Modification :I Other <br /> D Monitoring Well(S) #of wells a Soil Borings) a of borings �{,Geotechnical 5 #of borings <br /> Out-Of-Service Well C Out-Of-Service Well Renewal L I Cross-Connection Repair meet) <br /> []New Pump E Pump Replacement I Pump Repair Raise Well Casing <br /> W ELL CONSTRUCTION <br /> Drilling Method i i Mud Rotary 1 Air Rotary .I/!Auger I I Cable Tool C Push Point Other <br /> Proposed Well Depth ft Excavation in diameter i Open Bottom Gravel Pack/Gravel Size in diameter <br /> r;Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched I'Steel rl Plastic [I Stainless Steel I.7 Other <br /> Grout Seal Depth ft Neat Cement(94 lb bag/5-10 gal water) iI Sand Cement sack mixf7 gal water <br /> i Bentonite(20%solids) Other <br /> Grout Placement Method I Pumped I I Free Fall D Other I I Retardant/Accelerator(name) <br /> PEDESTAL Installed By F Driller D Pump Contractor F Other <br /> is Concrete Pedestal uDimensions:Width ft Length It Thick in Christy BOX S Stove Pipe <br /> PUMP n SubmersibleC Turbine n Other HP Pump Set ft 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 48 HOU VANC TICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE Managing Engineer DATE 1011512018 <br /> At C <br /> �A47. <br /> 18 2418 <br /> COU <br /> MFN�' <br /> YV <br /> T <br /> 11 LL 1111L <br /> D upAR M E N T US 11NImA 'CL Y <br /> Application Accepted By ate-t�57� � Area Employee ID#�` -� <br /> Grout Inspection Ey Dale / 72A.'11S SPECIAL Well Permit <br /> Pump Inspection By Date I I WAIVER Received <br /> Soil Boring Inspe tion By Date Constructed Well Depth ft <br /> L <br /> COMMENTS <br /> PE SC Received Check Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Cas Remitted Service Request# <br /> EHD 43-M revised 4/14/18 WELL/PUMP PERMIT <br />