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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 /> JOB ADDRESS Old Oak Drive and S B Street f Wil , 0lC� t/r=1 j< Cmr/ZIP Stockton,CA m <br /> CQ q. D <br /> CROSS STREET Ac I+Dk 4-y e APN 177`4 3 G o"` PARCEL SIZE )3 LAND USE APPLICATION# A <br /> m <br /> OWNER NAME Affordable Luxury Home PHONE 209-481-8861 or <br /> OWNER ADDRESS 5711 N.EI Dorado Street CITYISTATE/ZIP Stockton,CA 95207 <br /> CONTRACTOR Krazan&Associates.Inc. PHONE 559.3482100 <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 I_C-61 1 D-09 I I Other NUMBER 499908 EXPIRATIONDATE 10.'31/2020 <br /> DOMESnc WELL SAMPLING:LI General Mineral/Coliform Bacteria(4391) i Dibromochloropropane(4392)1;Arsenic(4393) <br /> INTENDED USE II Domestic/Private I Irrigation/Agricultural �Industrial Water Quality Monitoring ! Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK G New Well -i Replacement Well Well Alteration/Modification 1 i Other <br /> 7 Monitoring Well(s) #of wells Soil Boring(s) #of borings Geotechnical 2 #of borings <br /> n Out-Of-Service Well I Out-Of-Service Well Renewal I Cross-Connection Repair (10-15 Feet) <br /> I- New Pump 1 Pump Replacement i i Pump Repair 1 Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary I Air Rotary V Auger I Cable Tool I Push Point I I Other <br /> Proposed Well Depth )D-/So ft Excavation in diameter I Open Bottom i i Gravel Pack/Gravel Size in diameter <br /> L Conductor Casing in diameter / Conductor Casing Depth It <br /> Well Casing Diameter—in Thickness/Gauge/ASTM Sched I Steel I Plastic I Stainless Steel I i Other <br /> Grout Seal Depth 10-)S ft -/Neat Cement(94 Ib bag/5-10 gal water) Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) 1 1 Other <br /> Grout Placement Method I'Pumped I Free Fall I Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By II Driller C Pump Contractor I I Other <br /> LI Concrete Pedestal i Dimensions:Width It Length ft Thick in I Christy Box 1 1 Stove Pipe <br /> PUMP [ Submersible'. Turbine 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 /> MINI 48 HOU A TICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE <br /> Managing Engineer DATE 03/31/2020 <br /> _ YNAI <br /> T <br /> �W CO <br /> cqj-7r7 7 tt <br /> FN NTY <br /> I RTNjENT <br /> Z4— <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date 2 LO`C) Area 1 5 Employee ID# <br /> Grout Inspection By Date 1 SPECIAL Well Permit <br /> Pump Inspection By Date JJ I WAIVER.Received <br /> Soil Boring Inspection By Q Date G tiLU Constructed Well Depth It <br /> COMMENTS <br /> PE SC Received Chec Amount Date Permit/ Invoice# Well ID# <br /> Codes Info ash Remitted Service Re uest# <br /> EHD 43-06 revised 4/14/18 WELL/PUMP PERMIT <br />