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l <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 1150 Shaw Road ��/. �(/ojtCITY/Zip Stockton,California q5R 15 m <br /> CROSS STREET Shaw Avenue and Fremont St APIN 143-27-78 G-'PARCEL JIZE 6.17 LAND USE APPLICATION# O <br /> II-_ L11� ( m <br /> OWNER NAME TrioleTriole SS�Y-�.1 J►II�M/ A C ✓1 U J PHONE ryn, <br /> OWNER ADDRESS 1150 S_ ha Road /PO a--K a 1 1 j 4 CITY/STATE/ZIP Stockton,California <br /> CONTRACTOR Krazan&Associates.Inc. PHONE 5,59.348.2200 <br /> CONTRACTOR ADDRESS 215 W.Dakota Avenue CITY/STATEZP Clovis,California 93612 <br /> SUBCONTRACTOR Krazan&Associates,Inc. PHONE 559.348.2200 <br /> SUBCONTRACTOR ADDRESS 215W.Dakota Avenue CITY/STATEZP Clovis.California 93612 <br /> LICENSE VC-57 C-61 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 U Domestic/Private i Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> I Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK fl New Well i Replacement Well i Well Alteration/Modification Other <br /> i Monitoring Well(s) #of wells i Soil Boring(s) #of borings 4/Geotechnical 2 of borings <br /> I Out-Of-Service Well !Out-Of-Service Well Renewal Cross-Connection Repair <br /> Ci New Pump i Pump Replacement i Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary -/Auger Cable Tool Push Point Other <br /> Proposed Well Depth 15--50 ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br /> Grout Seal Depth15a— fl ft .t Neat Cement(94 lb bag/5-10 gal water) Sand Cement sack mix77 gal water <br /> Bentonite(20%solids) i Other <br /> Grout Placement Method Pumped i Free Fall Other 7`f' Retardant/Accelerator(name) <br /> PEDESTAL Installed By 1 1 Driller i i Pump Contractor i Other <br /> I Concrete Pedestal Dimensions:Width ft Length it Thick in Christy Box Stove Pipe <br /> PUMP i Submersiblei Turbine i 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 HOUR VAN ENO REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE Managing Engineer DATE 02/13/2020 <br /> Par _0 <br /> AA0 <br /> NTy <br /> Ej T kL <br /> ENT <br /> A TMENT U E NLyY_�!/� <br /> Application Accepted By Date I Area a/4 4 Employee ID# <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date n WAIVER Received <br /> Soil Boring Inspection By Date G Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info emitted Service Re uest# <br /> 5 <br /> EHD 43-06 revised 4/14/18 WELL/PUMP PERMIT <br />