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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 /> JOB ADDRESS N.Main�Street <br /> 'and Southland Avenue1P 1 CITvlLP Manteca,CA <br /> CROSS STREET 218-100-01 PARCEL SIZE LAND USE APPLICATION# o <br /> OWNER NAME Toinette Rossi Living Trust PHONE m <br /> OWNER ADDRESS P.O.Box 8837 CITYISTATE/ZIP Ripon,CA 95366 <br /> CONTRACTOR Krazan&Associates,Inc. PHONE 559.348.2200 <br /> CONTRACTOR ADDRESS 215 W.Dakota Avenue CITY/STATE/ZIP Clovis,California 93612 <br /> SUBCONTRACTOR Krazan&Associates,Inc. PHONE 559.348.2200 <br /> SUBCONTRACTOR ADDRESS 215 W.Dakota Avenue CITY/STATE/ZIP Clovis.California 93612 <br /> LICENSE /C-57 C-61 I D-09 i Other NUMBER 499908 EXPIRATION DATE 10.31.2020 <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391)i,Dibromochloropropane(4392);Arsenic(4393) <br /> INTENDED USE Domestic/Private Irrigation/Agricultural Industrial _Water Quality Monitoring n Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK i.I New Well ;_i Replacement Well i-I Well Alteration/Modification i i Other PA`_ <br /> i1 MonitoringWells #of wells Soil Boring(s)s #of borings 10 #of borings Iy!/ <br /> O 9O ✓�Geotechnical M <br /> I i Out-Of-Service Well a Out-Of-Service Well Renewal 1 Cross-Connection Repair (10-50 Feet) <br /> New Pum i Pump Replacement J Pump Repair 1 Raise Well Casing <br /> WELL CONSTRUCTION 0' O <br /> Drilling Method .,Mud Rotary Air Rotary /Auger 0/�Cable Tool - Push Point — Other <br /> Proposed Well Depth ft Excavation in diameter Open Bottom r- Gravel Pack/Gravel Size in diaT ,9 <br /> Conductor Casing n diameter / Conductor Casing Depth ft OgQV, <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched a Steel LlPlastic j�Stainless Steel Other H ,R�NM COU <br /> Grout Seal Depth fl (/Neat Cement(94 lb bag/5-10 gal wafer) Sand Cement sack mix/7 gal water h�Fp �Tq( <br /> Bentonite(20%solids) Other MENT <br /> Grout Placement Method Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal-'Dimensions:Width It Length ft Thick in !Christy Box 'i Stove Pipe <br /> POMP Submersiblem'Turbine n 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 DVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE Managing Engineer DATE <br /> 1 %S <br /> J <br /> H <br /> ML 1— sk".. 1 111.1 V 1. <br /> PA TMENT S 0 LY <br /> V � <br /> Application Accepted By Date Area mployee ID# <br /> Grout Inspection By Dale SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date�bl 0 Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received Check##/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info Cash Remitted Service Re t# <br /> EHD 43-08 revised 4/14/18 '/p��--r��`'/� WELL/PUMP PERMIT <br />