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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 52022 Pacific CITY/LP Stockton,CA <br /> CROSS STREET /�F'V L / APN 102-240-06 PARCEL SIZE- LAND USEAPPUCATION# C <br /> A <br /> INO Burger 626-813-8226 m <br /> OWNER NAME PHONE m <br /> OWNER ADDRESS 13502 Hamburger Lane 'CI1/STATE/21P Baldwin Park,CA 91706 <br /> CONTRACTOR Krazan&Associates,Inc. PHONE 559.348.2201-0+ <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/ZIP Clovis.California 93612 <br /> LICENSE /C-57 Ll C-61 CI D-09 ❑Other NUMBER 499908 EXPIRATION DATE 10.31.2020 <br /> DoMEsnc WELL SAMPLING:n General Mineral/Coliform Bacteria(4391)❑Dibromochloropropane,(4392)❑Arsenic(4393) <br /> INTENDED U n Domestic/Private ❑Irrigation/Agricultural ❑Industrial n Water Quality Monitoring n Soil Sampling/Characterization <br /> n Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK n New Well I1 Replacement Well i.i Well Alteration/Modification I I Other <br /> MonitoringWell(s) It of wells ❑Soil Borings) #ofborings VGeotechnical 6 aorbodngs <br /> Ll Out-Of-Service Well ❑Out-Of-Service Well Renewal i l Cross-Connection Repair (10-50 Ft) <br /> I l New Pum n Pump Replacement a Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method i i Mud RDlary�1"11Air Rotary V Auger n Cable Tool s Push Point ❑ Other <br /> Proposed Well Depth 'L5d It Excavation in diameter Open Bottom n Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth It <br /> Well Casing Diameter —in Thickness/Gauge/ASTM Sched (I Steel a Plastic U Stainless Steel '_1 Other <br /> Grout Seal Depth 101T /Neat Cement(94 Ib bag/5-10 gal water) a Sand Cement sack mix/7 gal water <br /> IJ Bentonite(20%solids) U Other <br /> Grout Placement Method I Pumped Il Free Fall OtherftMItLRetardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller n Pump Contractor n Other <br /> U Concrete Pedestal oDimensions:Width ft Length R Thick in L,Christy Box ❑Stove Pipe <br /> PUMP n Submersibles Turbine n 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 /> UM 48PR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGN TITLE Managing Engineer DATE 11/19/19 <br /> C <br /> ��VFO <br /> W22 '?o19 <br /> /N <br /> R ���Nry <br /> ENT <br /> FFF- <br /> WPA9(TMENT tISE JDNLY <br /> Application Accepted By to&117 Area Employee ID#� <br /> Grout Inspection By Date I SPECIAL Well Permit <br /> Pump Inspection By Dale ! WAIVER Received <br /> Soil Boring Inspection By Date 1 Z 1 Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Amount Date Permit/ Invoice# Well ID# <br /> Codes Into B Cash Remitted Service Request# <br /> EHD 43-0e revised 4/14/18 WELL/PUMP PERMIT <br />