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1 <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 /> Lathrop,CA N <br /> JOB ADDRESS 16850 Golden Valley Parkway CITYIZIP m <br /> ��f��W.iJ� •�L D <br /> CROSS STREET APN PARCEL SIZE Z <br /> ND USE APPLICATION# a <br /> m <br /> OWNER NAME BDDM Investments LLC PHONE 209-609-3417 P <br /> N <br /> OWNER ADDRESS 2205 Steinbeck DriveCITY/SrarE/LP Modesto,CA 95356 <br /> CONTRACTOR Krazan&Associates,Inc. PHONE 559.348'2200 <br /> CONTRACTOR ADDRESS 215 W.Dakota Avenue CITY/STATE/zip Clovis,California 93612 <br /> SUBCONTRACTOR Kiazan&Associates,Inc. PHONE 559.348.2200 <br /> SUBCONTRACTOR ADDRESS 215 W.Dakota Avenue CITY/STATE/2]P Clovis,California 93612 <br /> LICENSE /C-57 Ll C-61 J D-09 Other NUMBER 499908 ExPIRATION DATE 10.31.2020 /� <br /> DOMESTIC WELL SAMPLING:n General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392)n Arsenic(4393) I'�A <br /> INTENDED USE U Domestic/Private - Irrigation/Agricultural Industrial - Water Quality Monitoring -1 Sail Sampling/Characterization <br /> F)Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number o <br /> TYPE OF WORK ,..I New Well i Replacement Well Well Alteration/Modification i Other W <br /> U Monitoring Well(s) #of wells f Soil Boring(s) sof borings fj Geotechnical 8 #or borings SAN U 2019 <br /> U Out-Of-Service Well i Out-Of-Service Well Renewal l Cross-Connection Repair (10-50 Feet) qQU/N <br /> ❑New Pump U Pump Replacement i Pump Repair U Raise Well CasingC <br /> WELL CONSTRUCTION D NI�yy�.q Hn' <br /> Drilling Method n Mud Rotary ❑Air Rotary ./Auger iI Cable Tool I Push Point Other C ,MENr <br /> Proposed Well Depthjj)'-!�§ ft Excavation in diameter U Open Bottom i Gravel Pack/Gravel Size in diameter <br /> F1 Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched ❑Steel U Plastic 11 Stainless Steel i Other <br /> Grout Seal Depth i11t—Int It /Neat Cement(94 Ib bag/5-10 gal water) ]Sand Cement sack mix/7 gal water <br /> i Bentonite(20%solids) i Other <br /> Grout Placement Method i Pumped U Free Fall i Other `Retardant/Accelerator(name) <br /> PEDESTAL Installed By i Driller ! Pump Contractor Other <br /> I Concrete Pedestal[]Dimensions:Width ft Length ft Thick in U Christy Box Stove Pipe <br /> PUMP r'.Submersible, Turbine i 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 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> �- Managing Engineer 03/21/2019 <br /> $IQNED -!—� - �-----� TITLE 9 g 9 DATE <br /> AR MENT U E O LY <br /> Application Accepted By ate Area Employee ID#'� <br /> Grout Inspection By Date SPECIAL II Permit <br /> Pump Inspection By Date ? WAIVER Received <br /> Soil Boring Inspection Bykv, Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received hec Amount Date Permit/ Invoice# Well ID# <br /> Cods Info B ash Remitted Service Re uest# <br /> EHD 43-08 revised 4/14/18 WELL/PUMP PERMIT <br />