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1t <br /> 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 Auto Plaza Drive and Power Road CITY/zip Tracy CA m <br /> D <br /> CROSS STREET APN 212-270-21 PARCEL SIZE LAND USE APPLICATION# z <br /> m <br /> OWNER NAME Massod Feroz PHONE 510-305-7101 H <br /> OWNER ADDRESS 362 Quail Run Circle CITY/STATE/ZIP Tracy,CA 95377 <br /> CONTRACTOR Krazan&Associates,Inc,. PHONE 559 348.1200 <br /> CONTRACTOR ADDRESS 215 W.Dakota Avenue CITY/STATE/LP Clovis,California 93612 <br /> SUBCONTRACTOR Kiazan&Associates,Inc. PHONE 559.348.2100 <br /> SUBCONTRACTOR ADDRESS 215 W.Dakota Avenue CITY/STATE/ZJP Clovis.California 93612 <br /> LICENSE VOI C-61 D-09 Other NUMBER 499908 EXPIRATION DATE 1051.2020 <br /> DOMESTIC 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 Replacement Well Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells Soil Bonng(s) #ofborings f Geotechnical 6 #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 Casio <br /> WELL CONSTRUCTION <br /> Drilling Method I Mud Rotary Air Rotary .f Auger Cable Tool Push Point Other <br /> Proposed Well Depth ft Excavation in diameter Open Bottom i Gravel Pack/Gravel Size in diameter <br /> Il Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad , Steel i Plastic i Stainless Steel !i Other <br /> Grout Seal Depth ft V Neat Cement(94 Ib bag15-10 gal water) Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By 1 Driller Pump Contractor Other <br /> Concrete Pedestal .Dimensions:Width ft Length fl Thick in Christy Box . Stove Pipe <br /> PUMP 1-Submersible[ Turbine n Other HP Pump Set ft Standing Water Level fl <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 4 UR DVA CE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGN TITLE Managing Fingm<BwDATE 05/10/2019 <br /> YMENT <br /> E <br /> CEjvp p <br /> Y 14 2019 <br /> AQUIN C <br /> IEPENTAL <br /> UN1y <br /> ART NT <br /> 11 mi "I <br /> PA TMENT USt 0 LY <br /> Application Accepted By Date Area Employee ID#./F�1MW <br /> Grout Inspection By Dale 4qOPECIALell Permit '— <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By (a"J Date 2d G Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Amount Date Permit/ Invoice# Well ID# <br /> Codes Info Cash Remitted Service Re uest# <br /> EHD 43-08 revised 4/14/18 WELL/PUMP PERMIT <br />