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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 pAlli,L 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS •,1223 S Austin Road CITY/ZJP Q�"'' <br /> m <br /> CROSS STREET ' I. APN 226-150-027D <br /> G.�)� I� )PARCEL SIZE AND USE APPLICATION# p <br /> OWNER NAME -rc;(Illk'S NUrser� I GVK�1 KS, V�IIJ PHONE rOa, <br /> OWNER ADDRESS .'32238 Austin Ruad CITYISTATE/ZJP R pun,Culiforma <br /> CONTRACTOR Kriman R Associates Inr. PHONE 559 3-18 2200 <br /> CONTRACTOR ADDRESS •'15 W Dakola Aventl` CITY/STATEJZIP CIGviS.California 93612 <br /> SUBCONTRACTOR " A Associates,Inr:, PHONE 559.348.2200 <br /> SUBCONTRACTOR ADDRESS 215 W.Dakula AVenu- CITY/STATE/ZIP Clovis,Cnlifimla 93612 <br /> LICENSE C-57 C-61 0-09 ;Other NmwA 4998 EXPIRATION DATE 10.11 2018 <br /> DOMESTIC WELL SAMPLING: General MineraUColiform Bacteria(4391) ]Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private Irrigation/Agricultural Industrial I1 Water Quality Monitoring Solt Sampling/Charactenzatlon <br /> Public Water System <br /> H d,Herant I—Owner Wale,System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br /> Monitoring Wells) #of wells Soil Boring(s) #orbonngs �I Geotechnical won bmmgs <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair T—,7'1`r,�I <br /> New Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary ./Auger 11 Cable Tool Push Point Other <br /> 1 <br /> Proposed Well Depth 15 -SrO fl Excavation in diameter I'Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth It <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br /> Grout Seal Deplh(ti O it /Neat Cement(94 Ib bag/5-10 gal wafer) Sand Cement sack mix/7 gal water <br /> Bentomle(20%solids) Other <br /> Grout Placement Method Pumped Free Fall j1Q0Ihe, 'ti Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width A Length it Thick in Christy Box Stove Pipe <br /> PUMP Submersible Turbine Other HP Pump Set it Standing Water Level it <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 /> .LOO iIMUNI•18 UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNEQ TITLE DATE I' Zf'2�1 <br /> -- otMFR <br /> 71 <br /> VFD <br /> -- 8 Z418 <br /> Tj COVN <br /> n <br /> TMFNT <br /> P A T M E N T U E O L / <br /> Application Accepted By D le Area'6'i--�-� Employee ID# til/ <br /> Grout Inspection Ry Dale SPECIAL Well Permit: <br /> Pump Inspection By Dale WAIVER Received <br /> Soil Boring Inspection By'� Date ) Constructed Well Depth ft <br /> COMMENTS t ' <br /> PE SC Received Check Amount Date Perrnitl Invoice# Well ID# <br /> Codes Info Remitted ervic Re uest# <br /> O S <br /> EHC 43-06 1-sed a1 4118 WELL,PUMP PERMIT <br />