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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)466-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 1263 Cottage Court CITY/ZIP Manteca,California <br /> D <br /> CROSS STREET Cottage Ave APN 208-26-9 6 PARCEL SIZE,.-'. I, LAND USE APPLICATION# m <br /> OWNER NAME G.L.Bruno&Associates 1 Ute,- {V PHONE 559.454.7744 N <br /> OWNER ADDRESS 855 M Street,Tenth Floor CITY/STATE/ZIP Fresno,California 93721 <br /> CONTRACTOR Krazan&Associates,Inc. PHONE 559.348.2200 <br /> CONTRACTOR ADDRESS 215 W.Dakota Avenue CITY/STATEIZIP Clovis,CA 93612 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATE/ZIP <br /> LICENSE J C-57 C-61 D-09 Othef NUMBER 499908 EXPIRATION DATE 10/31/2018 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br /> INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring ^oil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water z5ystern Name ContactNameor one um er <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br /> Monitoring Wells) #of wells Soil Boring(s) a of bDnnge -/Geotechnical 5 u of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair (10-50Feet) <br /> New Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary Auger CCable Tool Push Point Other <br /> Proposed Well Depth 10-50 It Excavation !A.' in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter 44—in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br /> Grout Seal Depth ft V/Neat Cement(94/b bag/5-10 gal water) Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method umped Free Fall Other Retardant/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 ft Standing Water Level K <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 /> 4 HO VA ICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE Managing Engineer DATE 09/20/17 <br /> IVO <br /> Pe 1 2 1 2012 <br /> Word <br /> b ENTAL HEALTH <br /> y T/SERVICES <br /> N J7. <br /> ­_ IRy, <br /> � <br /> DEPARTMENT USE ONLY <br /> /,Ar'' ) (� <br /> Application Accepted By / W yy Date / / Area S ��1 G r1)'t rl Employee ID# If h M e <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring I spection By Date Construct d Well Depth ft F <br /> COMME TS t/✓ <br /> PE SC Received heck Amount Date Permit! Invoice# Well ID# <br /> Codes Info By s Remitted a ice Request# <br /> X13/ 15 <br /> EH D 43-06 WELL/PUMP PERMIT <br /> 4/30/12 <br />