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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 /> so <br /> JOB ADDRESS Louise Avenue and McKinley Avenue F( j� CITY/ZIP Lathrop,CA <br /> � D <br /> CROSS STREET APN PARCEL SIZE LAND USE APPLICATION# o <br /> A <br /> OWNER NAME City of Lathrop PHONE 209-941-7438 H <br /> OWNER ADDRESS 390 Towne Centre Drive CITY/STATE/ZIP Lathrop,CA 95330 <br /> CONTRACTOR Krazan&Associates,Inc. PHONE 558.346.2200 <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/STATEILP Clovis,California 93612 <br /> LICENSE /C-57 C-61 I D-09 Othef NUMBER 499906 EXPIRATION DATE 10.31.2016 <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE ❑Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring i,Soil Sampling/Characterization <br /> n Public Water System <br /> If different from Owner. Water System Name Contact Name of Phone Number <br /> TYPE OF WORK ❑New Well Replacement Well I Well Alteration/Modification Other <br /> ❑Monitoring Well(s) #of wells ❑Soil Borings) #of borings f Geotechnical 4 #of borings <br /> D Out-Of-Service Well CI Out-Of-Service Well Renewal Cross-Connection Repair (5-15Feet) <br /> New Pum ❑Pump Replacement I I Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary I-7 Air Rotary /Auger Cable Tool Push Point ❑ Other <br /> Proposed Well Depth ft Excavation in diameter D Open Bottom Gravel Pack/Gravel Size in diameter <br /> :r Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched D Steel Plastic Stainless Steel Other <br /> Grout Seal Depth ft /Neat Cement(94 Ib bag/5-10 gal water) Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped U 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 Stove Pipe <br /> PUMP Submersible Turbine 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 A ANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE Managing Engineer DATE 04)19/2019 <br /> iepolVNT <br /> ED <br /> 6 2019 <br /> f �N C�U� <br /> 7y <br /> ART WplVT <br /> A R M E N T U E O L Y <br /> Application Accepted By ate Area E IoyeeID#� <br /> Grout Inspection By Date SPECIAL Well ermit <br /> Pump Inspection By Date i WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> ## <br /> COMMENTS <br /> PE SC Received (\Check#V Amount Permit/ <br /> odes Info B mitt d Date Service Request# Invoice It Well ID# <br /> 337 <br /> EH043-06 revised 4/14/18 <br /> WELL/PUMP PERMIT <br />