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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 /> Joe ADDRESS *DM <br /> Cochran Road Lodi,CA W <br /> CITY/ZIP <br /> a <br /> CROSS STREET AP d PARCEL SIZE��AND USE APPLICATION# p <br /> OWNER NAMEquared Homes m <br /> PHONE 209-565-3624 y <br /> OWNER ADDRESS 4719 Quail Lakes Drive,Suite G /�- 3( A, h�,/� CITYISTATE/ZIPStockton,CA 9520! <br /> CONTRACTOR Krazan&Associates,Inc. Gam` f�Cl PHONE 559.3482200 <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 CIN/STATE/ZIP Clovis,California 93612 <br /> LICENSE /C-57 0 C-61 0 D-09 ❑Other NUMBER 499908 EXPIRATION DATE 10.31.2020 <br /> DOMESTIC WELL SAMPLING:Ll General Mineral/Coliform Bacteria(4391)0 Dibromochloropropane(4392)0 Arsenic(4393) <br /> INTENDED USE ❑Domestic/Private 0 Irrigation/Agricultural ❑Industrial 0 Water Quality Monitoring 0 Soil Sampling/Characterization <br /> 0 Public Water System <br /> It different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK G New Well 0 Replacement Well 0 Well Alteration/Modification 1-1 Other <br /> i Monitoring Well(s) #of wells 0 Soil Boring(s) #of borings fj Geotechnical 5 #of borings <br /> U Out-Of-Service Well 0 Out-Of-Service Well Renewal 0 Cross-Connection Repair 710--50 Feet) <br /> n New Pump n Pump Replacement ❑Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary rt Air Rotary �/!Auger Cable Tool —Push Point Other <br /> Proposed Well Depth-CW It Excavation in diameter I i Open Bottom - Gravel Pack/Gravel Size in diameter <br /> n Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM SchedSteel I_ Plastic Stainless Steel _!Other <br /> Grout Seal Depth 113 - (I ft ✓Neal Cement(94/b bag/5-10gal wafer) Sand Cement sack mix/7 gal water <br /> i i Bentonite(20%solids) Other <br /> Grout Placement Method ; Pumped _;Free Fall i Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By I'Driller i Pump Contractor I' Other <br /> LI Concrete Pedestal❑Dimensions:Width ft Length ft Thick in ii Christy Box J Stove Pipe <br /> PUMP n Submersible('Turbine 0 Other HP Pump Set It 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 /> 11 <br /> M 48 HOU VA E NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED r TITLE Managing Engineer DATE 10/11/2019 <br /> 11114 <br /> Ar <br /> r ,s2o19 <br /> QUIH <br /> N F•gR�yTt/Atfluff#_ <br /> Ty <br /> MFNT <br /> PA TMENT U E ONNNLY `// <br /> Application Accepted By Date 1� Area i� Employee ID# <br /> Grout Inspection By Date ❑ SPECIAL well Permit <br /> Pump Inspection By Date Fl WAIVER Received <br /> Soil Boring Inspection By �� Date Z Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check Amount Da Permit/ <br /> odes Info B emitted Service Re ues[# Invoice# Well ID# <br /> EMD 43-06 revised 4/14/18 <br /> WELL/PUMP PERMIT <br />