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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTYENVIRONMENTALHEALTH 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 522 W.Grant Line Road CITY/ZIP Tracy,California m <br /> �J� D <br /> CROSS STREETS{ APN 233-030-09 PARCEL SIZE LAND USE APPLICATION# S <br /> G m <br /> OWNER NAME Soosan Ikod PHONE 510-421-1227 <br /> OWNER ADDRESS 3058 Flora Ct CITY/STATEIZJP Pleasanton,CA 94588 <br /> CONTRACTOR Krazan&Associates,Inc. PHONE 559.348.2200 <br /> CONTRACTOR ADDRESS 215 W.Dakota Avenue CITYISTATE/ZIP Clovis,California 93612 <br /> SUBCONTRACTOR Krazan&Associates,Inc. PHONE 559.348.2200 <br /> SUBCONTRACTOR ADDRESS 215 W.Dakota Avenue CITY/STATE/ZJP Clovis,California 93612 <br /> LICENSE /C-57 C-61 D D-09 ❑Other NUMBER 499908 EXPIRATION DATE 10.31.2020 <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)❑Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE D Domestic/Private D Irrigation/Agricultural ❑Industrial D Water Quality Monitoring D Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well F Replacement Well ❑Well Alteration/Modification ❑Other <br /> Monitoring Wells) #of wells ❑Soil Boring(s) #or borings Geotechnical_2 Nor borings <br /> Out-Of-Service Well ❑Out-Of-Service Well Renewal v Cross-Connection Repair <br /> New Pum n Pump Replacement D Pump Repair rl Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Ro�ry ,Air Rotary �/f Auger :7 Cable Tool F Push Point Other <br /> Proposed Well Depth(() -40 ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> n Conductor Casing in diameter / Conductor Casing Depth fl <br /> Well Casing Diameter in Thickness/Gauge/ASTM Schad Steel Plastic Stainless Steel Other <br /> Grout Seal Deptni(}�« v(Neat Cement(94/b bag/5-10 gal wafer) i Sand Cement sack mix17 gal water <br /> Bentonite(20%solids) i Other <br /> Grout Placement Method Pumped Free Fall Other , Retardant/Accelerator(name) <br /> PEDESTAL Installed By :.i Driller I Pump Contractor ❑ Other <br /> Concrete Pedestal I]Dimensions:Width ft Length ft Thick in G Christy Box ❑Stove Pipe <br /> PUMP ❑Submersible Turbine 11 Other HP Pump Set If 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 ADV CE OTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED ` TITLE Managing Engineer DATE 10/30/2019 <br /> YMFNt <br /> Is- <br /> ?�19 <br /> N7AI�Y <br /> rMFNr <br /> A TMENT U E NLY P�� - <br /> Application Accepted By to Area Employee ID# <br /> Grout Inspection By Date I_ SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring I s ction By N Date ho` Constructed Well Depth It /� l <br /> COMMENTS llLv�y%//l <br /> PE SC Received hec Amount Permit[Codes Info as er itte D to Service Request# Invoice# WeIIID# <br /> W <br /> EH043-08 revised 4/14118 WELL/PUMP PERMIT <br />