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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 /> y <br /> JOB ADDRESS 1279 West Lathrop Road CITY/ZIP Manteca,CA <br /> m <br /> D <br /> CROSS STREET Union Road APN 204-100-23 PARCEL SIZE LAND USE APPLICATION# °oA <br /> m <br /> OWNER NAME Rupinder Dhillon PHONE 408-687-1492 v, <br /> OWNER ADDRESS 28214 Leaf Drive CITYISTATE/ZIP Tracy,CA 95304 <br /> CONTRACTOR Krazan 8 Associates,Inc PHONE 559 348 2200 <br /> CONTRACTOR ADDRESS 215W Dakota Avenue CITY/STATE/ZIP C,Iows,Califo,ma 93612 <br /> SUBCONTRACTOR Krazan K Associates,Inc PHONE '59.348 2200 <br /> SUBCONTRACTOR ADDRESS 215 W Dakota Avenue: Cm/STATE/ZJP Clo,is.California 93612 <br /> LICENSE VC-57 C-61 0-09 Other NUMBER 409908 EXPIRATION DATE 10.31.2020 <br /> DoMEsnc WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well i Replacement Well i Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells Soil Boring(s) sof borings f Geotechnical 10 #of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair (10-50 Feet) <br /> New Pump Pump Replacement .Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary ✓Auger Cable Tool Push Point - Other <br /> Proposed Well Depth It Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth It <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br /> Grout Seal Depth ft ✓Neat Cement(94 Ib bag/5-10 gal water) Sand Cement sack mtxl7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped Free FalljXQther7A*f11�j!eRetardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal ,Dimensions:Width ft Length ft Thick in Christy Box Stove Pipe <br /> PUMP Submersible Turbine Other HP Pump Set It 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 HOUR?A NC TICS RE UIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE Managing EnginBer DATE 5)10/2019 <br /> I yMEIVT <br /> CE�VE p <br /> M4Y1 � 2O19 <br /> NV1R pNM COU-rAtNTY <br /> LTH!DEPS Nr <br /> EPA <br /> c TMENT U SIE 0 LY <br /> WW <br /> Application Accepted By Dale Area Employee ID# <br /> Grout Inspection By L-i L 0< ,i5 AVDate 3 SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Bonnspeclion By Date Co tructed Well Depth <br /> COM ENTS SSC Z7C 1 f <br /> PE Sc ReceivedCheck# Amount Permit/Codes Info B Remitted Date jrServiceRe uest# Invoice# WeIIID# <br /> EHD 43-08 revised 4/14/18 WELL/PUMP PERMIT <br />