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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-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Joe ADDRESS 3143 W.Benjamin Holt Drive CITY/ZIP Stockton,CA m <br /> D <br /> CROSS STREET Constitution Way APN ^1'00-170-% V� PARCEL SIZE t LAND USE APPLICATION# <br /> N <br /> a <br /> OWNER NAME <br /> McDonalds USA *1— v•�3 PHONE 925-949-4000 <br /> OWNER ADDRESS 2999 Oak Road,Suite 900IT1/STATE/ZIP Walnut Creek,CA 94597 <br /> wj <br /> CONTRACTOR Krazan&Associates,Inc. ' -[S-r'A (JPHONE 559.3482200 <br /> CONTRACTOR ADDRESS 215 W.Dakota Avenue CITY/STATE/ZIP Clovis,California 93612 <br /> SUBCONTRACTOR 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 1 C-61 n D-09 1_1 Other NUMBER 499908 EXPIRATION DATE 10.31 2020 <br /> DOMEsnc WELL SAMPLING:L General Mineral/Coliform Bacteria(4391)It Dibromochloropropane(4392)i I Arsenic(4393) <br /> INTENDED USE I Domestic/Private :-7 Irrigation/Agricultural L Industrial n Water Quality Monitoring I I Soil Sampling/Characterization <br /> u Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK I New Well i I Replacement Well ❑Well Alteration/Modification L Other <br /> I Monitoring Well(s) #of wells L Soil Boring(s) a ofborings f Geotechnical 5 a of borings <br /> I Out-Of-Service Well n Out-Of-Service Well Renewal i-I Cross-Connection Repair (10-50 Feet) <br /> I]New Pum i]Pump Replacement ❑ Pump Repair ❑Raise Well Casio <br /> WELL CONSTRUCTION <br /> Drilling Method I Mud Rotary i Air Rotary Auger i-1 Cable Tool ❑ Push Point I I Other <br /> Proposed Well Depth ft Excavation in diameter ri Open Bottom [I Gravel Pack/Gravel Size in diameter <br /> L Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched 7 Steel i]Plastic L Stainless Steel [i Other <br /> Grout Seal Depth ft V Neat Cement(94 lb bag/5-10 gal water) a Sand Cement sack mW7 gal water <br /> o Bentonite(20%solids) n Other <br /> Grout Placement Method Li Pumped a Free Fall I i Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By I I Driller -1 Pump Contractor it Other <br /> 1 Concrete Pedestal[]Dimensions:Width ft Length ft Thick in n Christy Box L Stove Pipe <br /> PUMP n Submersible Turbine F 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 /> [MUM 48 HO DV C TIC IRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE Managing Engineer DATE 03/08/2019 <br /> PAYMENT <br /> DECEIVED <br /> 2019 <br /> N JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> H LTH DEPARTMENT <br /> PA TMENT U5,E N Y <br /> Application Accepted By ate AreaZ/4;1 Employee ID# <br /> Grout Inspection By I A Dale I I SPECIAL Well Permit <br /> Pump Inspection B Date I WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check Amount Permit/ <br /> Codes Info B as Remitted Date Service Re uest# Invoice# Well ID# <br /> 33 ,t�3 t <br /> EHD 43-08 revised 4114118 WELL/PUMP PERMIT <br />