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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 /> to <br /> JOB ADDRESS 1263 Cottage Court CITY/ZIP Manteca,California <br /> r� � R D <br /> CROSS STREET Cottage Ave APN 208-2 V PARCEL SIZE Q' jaAND USE APPLICATION# m <br /> OWNER NAME G.L.Bruno&Associates .4r- ,g-� PHONE 559.454.7744 N <br /> OWNER ADDRESS 855 M Street,Tenth Floor/�� S �CITY STATE/ZIP Fresno,California 93721 <br /> CONTRACTOR Krazan&Associates,Inc. 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 V C-57 C-61 D-09 Other NUMBER 499906 EXPIRATION DATE 10/31/2020 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range 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 tiyStern Name on a arae or one Number <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells Soil Boring(s) #or borings Geotechnical 5 #of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair (10-50Feet) <br /> New Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary VAuger Cable Tool Push Point Other <br /> Proposed Well Depth 10-50 ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth It <br /> Well Casing Diameter412 in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br /> Grout Seal Depth ft Nf Neat Cement(94 Ib bag15-10 gal water) Sand Cement sack mixl7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped Free Fail Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width ft Length fl Thick in Christy Box Stove Pipe <br /> PUMP Submersible Turbine 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 24 R VAN OTICE REQ IRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE Managing Engineer DATE 01/10/2019 <br /> A <br /> � ��I <br /> C <br /> 1,4fZ <br /> �A TMENT SE NLY <br /> Application Accepted By le Area Employee ID# , <br /> Grout Inspection By Date 40SIE11!Well Permit <br /> Pump Inspection By A Date J �� (J �� [.1 WAIVER Received <br /> Soil Boring Inspection By Date Cons <br /> f r ° tructed Well Depth It <br /> COMME TS _.._.— <br /> rotas -- <br /> PE SC Received Chec mount Date Permit/ Invoice# Well ID# <br /> Codes Info By fternitted Service Request# <br /> IS <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4/30112 <br />