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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 /> rn <br /> JOB ADDRESS I'�>cadero Avenue and MacArthur Road Cm/ZIP Tracy.CA � <br /> m <br /> D <br /> CROSS STREET APN `1- '' PARCEL SIZE LAND USE APPLICATION# <br /> 0o 971 O <br /> � A <br /> Hufl Construction Cu m <br /> OWNER NAME / PHONE /� a <br /> OWNER ADDRESS 4917 St.ddard ROad / �!Q S/Num CITY/STATE/ZIP Modesto.CA 95356 lJ51L �Su <br /> CONTRACTOR Krazan 8 Associates,Inc. PHONE 559.348.2200 <br /> CONTRACTOR ADDRESS 215 W.Dakota Avenue CITY/STATE/ZJP Clovis,California 93612 <br /> SUBCONTRACTOR Krazan 8 Associates,Inc PHONE 559,348.2200 <br /> SUBCONTRACTOR ADDRESS 215 W.Dakota Ave,,,- CITY/STATEMP Ciovls,Cdlifornla 93612 <br /> LICENSE V C-57 C-61 Li D-09 L Other NUMBER 499908 EXPIRATION DATE 10 31.202C <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) 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 D New Well Replacement Well Well Alteration/Modification -1 Other <br /> ❑Monitoring Well(s) #of wells Soil Bonng(s) #of borings N/Geotechnical 5 of loadings <br /> iI Out-Of-Service Well Out-Of-Service Well Renewal �.i Cross-Connection Repair (10-50 Feel) <br /> New Pum i]Pump Replacement Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary 17 Air Rotary ./Auger Cable Tool Push Point Other <br /> Proposed Well Depth v ft Excavation in diameter a Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth If <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel Plastic Stainless Steel Other <br /> Grout Seal DepthI()—CiD It ./Neat Cement(94 Ib bag/5-10 gal water) Sand Cement sack mix(]gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped L Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller i Pump Contractor Other <br /> Concrete Pedestal[]Dimensions:Width It Length It 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 HO f>DV N NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE Managing Engineer DATE 09/27/2015 <br /> k4 F <br /> 1 <br /> �AV c� <br /> gR���TY <br /> PALe rrMENT U E O LY �����,,////�� <br /> Application Accepted By a Area Employee ID# 6T 4 <br /> Grout Inspection By Date If SPECIAL Well Permit <br /> Pump Inspection By A Date WAIVER Received <br /> —huSoil Boring Inspection By Date Z 3 I Constructed Well Depth ft <br /> COMMENTS <br /> lr <br /> PE Sc Received hec Amount Permit/ <br /> Codes Ifo B ash emitted Da Service Re uest# Invoice# Well ID# <br /> EHD 43-05 revised 4/14/18 WELL/PUMP PERMIT <br />