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5 <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 209 953-769'7,F/OR NSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS Howland Road and Yosemite Avenue Vp, ITy/7r Lathrop,CA m <br /> CROSS STREET �� APN — PARCEL SIZE LAND USE APPLICATION# z <br /> OWNER NAME Harwinder Singh ` PHONE 408-217-4562 m <br /> OWNER ADDRESS 2137 Amberwood Lane CITY/STATE/ZIP San Jose,CA 95132 <br /> CONTRACTOR Krazan&Associates,Inc. PHONE 559.348.2200 <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 CITY/STATE/ZIP Clovis.California 93612 <br /> LICENSE /C-57 ❑C-61 ❑D-09 ❑ Other NUMBER 499908 EXPIRATION DATE 10.31.20 <br /> DOMESTIC WELL SAMPLING:0 General Mineral/Coliform Bacteria(4391)0 Dibromochloropropane(4392)0 Arsenic(4393) <br /> INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> D Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> ❑Monitoring Well(s) #of wells ❑Soil Bodng(s) a of borings I Geotechnical 5 a of borings <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair (10-50 Feet) <br /> ❑New Pump ❑Pump Replacement ❑ Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑yr Rotary ./Auger ❑Cable Tool ❑Push Point ❑ Other <br /> Proposed Well Depth�ft Excavation in diameter ❑Open Bottom D Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth It <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched 0 Steel ❑Plastic D Stainless Steel ❑Other <br /> Grout Seal Dept ft ,(Neat Cement(94/b bag/5-10 gal water) ❑Sand Cement sack mix/7 gal water <br /> D Bentonite(20%solids) ❑Other <br /> Grout Placement Method ❑Pumped ❑Free Fall Otherq D Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> 0 Concrete Pedestal❑Dimensions:Width It Length ft Thick in ❑Christy Box D Stove Pipe <br /> PUMP D SubmersibleD Turbine D Other HP Pump Set ft Standing Water Level ft <br /> I HEREBY CERTIFY THAT 1 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 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIM M 48 HO AD ANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> ` <br /> Managing Engineer <br /> SIGNED TITLE 9 9 9 DATE 11/20/2019 <br /> ®® �® <br /> Jaq <br /> 0j�cO <br /> ' PA TMENT U E qNLY <br /> Application Accepted By Date /21 <br /> Area[" "/'j�����`/mployee ID# <br /> Grout Inspection By Date ❑ SPECIAL.WBII Permit <br /> Pump Inspection By Date EI WAIVER Received <br /> Soil Boring Inspection By Date Z/ l Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received Amount Date Permit/ Invoice# Well ID# <br /> odes Info B Cash emitted Service Re uest# <br /> I wpocI40326 <br /> EHD 43-06 revised 4/14/18 WELL/PUMP PERMIT <br />