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t <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 S7Mt CITY/LP Stockton,CA <br /> APN I%!"D7V�I� D <br /> CROSS STREET PARCELSIZE USE APPLICATION# p <br /> OWNER NAME Sazzadul Khan <br /> PHONE 650-888-2524 N <br /> OWNER ADDRESS 3326 Ariel Joshua Ct CITY/STATE/ZIP San Jose,CA <br /> CONTRACTOR Krazan&Associates,Inc. PHONE 559.34$.2200 <br /> CONTRACTOR ADDRESS 215 W.Dakota Avenue CITY/STATE/LP Clovis,California 93612 <br /> SUBCONTRACTOR Krazan&Associates,Inc. PHONE 559.348.2200 <br /> SUBCONTRACTOR ADDRESS 215 W.Dakota Avenue CITY/STATE/LP Clovis,California 93612 <br /> LICENSE VC-57 P C-61 D D-09 Other NUMBER 49990$ EXPIRATION DATE 10.31.2020 <br /> DOMESTIC WELL SAMPLING:I General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE ❑Domestic/Private Irrigation/Agricultural - Industrial -'Water Quality Monitoring --.Soil Sampling/Characterization <br /> Public Water System <br /> It different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK L New Well C Replacement Well J Well Alteration/Modification 0 Other <br /> 0 Monitoring Wells) #of wells 0 Soil Boring(s) a of borings -Z Geotechnical 3 If of borings <br /> El Out-Of-Service Well D Out-Of-Service Well Renewal J Cross-Connection Repair 10-50 Feet <br /> J New Pump D Pump Re lacement CI Pump Repair U Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method D Mud Rytary Ll Air Rotary Auger 11 Cable Tool 11 Push Point O Other <br /> Proposed Well Dept)61 "S�1 ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> 0 Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter�,ink Thickness/Gauge/ASTM Sched El Steel 0 Plastic 0 Stainless Steel D Other <br /> Grout Seal Depto —7V ft V Neal Cement(94 lb bag/5-10 gal water) 0 Sand Cement sack mix/7 gal water <br /> 0 Bentonite(20%solids) 0 Other <br /> Grout Placement Method 1,Pumped 0 Free Fall Other a Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller 0 Pump Contractor ❑ Other <br /> Concrete Pedestal DDimenslons:Width ft Length ft Thick in 0 Christy Box 0 Stove Pipe <br /> Pu MP Submersible i 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 H U A VA OTICE REQ IRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE Managing Engineer DATE 10.11.19 <br /> ---------------------------------------- <br /> SEC MENT <br /> EIVEp <br /> ----------------------------------- <br /> HCl 16 ?019 <br /> VI pUpN CpuNTY <br /> Sit 7H DE ARTtiAL <br /> =FLA <br /> ENT USE O LY <br /> Application Accepted By ate <br /> Area mployee ID#jj�� <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date f D i Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received CheC Amount Permitl <br /> odes Info ash Remitted Date ServiceRe uest# Invoice# Well ID# <br /> t •1 <br /> EHD 43-06 revised 4/14118 <br /> WELL/PUMP PERMIT <br />