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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 /> rn <br /> JOB ADDRESS 1279 West Lathrop Road CITY/ZIP Manteca CA <br /> D <br /> 0 <br /> CROSS STREET Union Road APN 204-100-23 PARCEL SIZE LAND USE APPLICATION# m <br /> OWNER NAME Rupinder Dhillon PHONE 408-687-1492 v! <br /> OWNER ADDRESS 28214 Leaf Drive CITY/STATEIZIP Tracy CA 95304 <br /> CONTRACTOR KraZan&Associates,Inc. PHONE 559.348.2200 <br /> CONTRACTOR ADDRESS 215 W.Dakota Avenue CITY/STATEIZIP Clovis,California 93612 <br /> SUBCONTRACTOR Krazan&Associates,Inc. PHONE 559.348.2200 <br /> SUBCONTRACTOR ADDRESS 215 W.Dakota Avenue CITY/STATEIZIP Clovis.California 93612 <br /> LICENSE /C-57 n C-61 n D-09 U Other NUMBER 499908 EXPIRATION DATE 10.31.2020 <br /> DOMESTIC WELL SAMPLING:0 General Mineral/Coliform Bacteria(4391)n Dibromochloropropane(4392)0 Arsenic(4393) <br /> INTENDED USE D Domestic/Private n Irrigation/Agricultural n Industrial s Water Quality Monitoring D Soil Sampling/Characterization <br /> D Public Water System <br /> If different from Owner: Waley System Name Contact Name or Phone Number <br /> TYPE OF WORK 0 New Well D Replacement Well U Well Alteration/Modification D Other <br /> 0 Monitoring Well(s) #of wells 0 Soil Boring(s) •or borings N16 Geolechnlcal 10 sof borings <br /> I)Out-Of-Service Well 0 Out-Of-Service Well Renewal D Cross-Connection Repair (10-50 Feet) <br /> 0 New Pump D Pump Replacement U Pump Repair 0 Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method n Mud Rotary 0 Air Rotary Auger s Cable Tool n Push Point n Other <br /> Proposed Well Depth ft Excavation in diameter rl Open Bottom n Gravel Pack/Gravel Size in diameter <br /> n Conductor Casing in diameter / Conductor Casing Depth It <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad u Steel U Plastic D Stainless Steel U Other <br /> Grout Seal Depth ft V Neal Cement(94 Ib bag/5-10 gal water) U Sand Cement sack mixr7 gal water <br /> D Bentonite(20%solids) D Other <br /> Grout Placement Method n Pumped I7 Free Fall l Other s Retardant/Accelerator(name) <br /> PEDESTAL Installed By C Driller '1 Pump Contractor liOther <br /> U Concrete Pedestal UDlmensions:Width If Length fl Thick in 0 Christy Box 0 Stove Pipe <br /> PUMP n Submersibles Turbine 0 Other HP Pump Set It Standing Water Level ft <br /> 1 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 H URA NC TICS RE UIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE Managing Engineer DATE 5/10/2019 <br /> RFCMENT <br /> E/VED <br /> MAY 14 2019 <br /> IV p U1N�O(Ily <br /> LTH p PaR MENS <br /> EPA TMENT US O LY <br /> c <br /> Application Accepted By Dale Area!�Employee ID# <br /> Grout Inspection By Dale ❑ SPECIAL Well P."nit <br /> Pump Inspection By Dale i7 WAIVER Received <br /> Soil Boring Inspection By Dale Constructed Well Depth It <br /> COMMENTS <br /> PESC Received Check# Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By_ as Remitted pServiceRe uest# <br /> it ILA pwaf <br /> EHD 43-M revl.sd 4/14118 WELL/PUMP PERMIT <br />