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1 <br /> WELL/PUMP PERMIT <br /> s SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CAIL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Scott Creek Drive&Regatta Lane Stockton,CA <br /> JOB ADDRESS CITY/ZIP <br /> D <br /> CROSS STREE APN PARCEL SIZE 2 -' LAND USE APPLICATION# o <br /> ,/ A <br /> OWNER NAME KB Homes ? /�/ Y PHONE ai <br /> OWNER ADDRESS 3005 Douglas Boulevard Suite 250/jQ/Db Liu[ 7 CITY/STATE/ZIP Roseville,CA 95661 <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/ZIP Clovis,California 93612 <br /> LICENSE SIC-57 I I C-61 1,D-09 I Other NUMBER 499908 EXPIRATION DATE 10.31."2.020 <br /> DOMESTIC WELL SAMPLING:n General Mineral/Coliform Bacteria(4391)11 Dibromochloropropane(4392) 7 Arsenic(4393) <br /> INTENDED USE Domestic/Private Il Irrigation/Agricultural n Industrial Water Quality Monitoring ❑Soil Sampling/Characterization <br /> D 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 r Soil Boring(s) p of bodngs f Geotechnical 6 M of borings <br /> :J Out-Of-Service Well Li Out-Of-Service Well Renewal I Cross-Connection Repair (10-50 Feet) <br /> -1 New Pum '.I Pump Replacement a Pump Repair I Raise Well Casing <br /> WELL CONSTRUCTION rPA MFNT <br /> Drilling Method Mud Rotary Air Rotary /Auger Cable Tool Push Point Other ���� <br /> Proposed Well Depth ft Excavation in diameter P Open Bottom fl Gravel Pack/Gravel Size in diameter D <br /> rl Conductor Casing in diameter / Conductor Casing Depth ft U/lU7, 1 <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched -Steel Plastic Stainless Steel Other 2019 <br /> Grout Seal Depth ft V Neat Cement(94 Ib bag/5-10 gal wafer) Sand Cement sack mix/7 gal WM J <br /> Bentonite(20%solids) I7 Other OgQUrN <br /> Grout Placement Method Pumped : Free Fall Other Retardant/Accelerator(name) T IR )Q O(/N]�. <br /> H�EpgR 7k <br /> PEDESTAL Installed By Driller Pump Contractor Other MFNT <br /> Concrete Pedestal..J Dimensions:Width It Length ft Thick in L)Christy Box Stove Pipe <br /> PUMP Submersiblei Turbine n 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 /> f IMUM 48 H VANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNE 1 , TITLE Managing Engineer DATE 7 ' <br /> 11 N NL <br /> RVE <br /> AL1'(I <br /> T V1 E <br /> PA TMENT UY <br /> Application Accepted By Date r Are B� Employee ID# <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By ItDate WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Receivedheck Amount Date Permit/ Invoice# Well ID# <br /> Codes Info sh Remitted Service Re uest# <br /> EHD 43-06 revised 4/14/18 q y79�s- WELL/PUMP PERMIT <br />