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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 /> rn <br /> JOB ADDRESS Malisa Way and Michael Way 303 1�lit�lSlh CITYZStockton,CAP � <br /> CROSS STREET i •:1 f '" �s Y APN 1 7 7g/q 0 41 PARCEL SIZE LAND USE APPLICATION# A <br /> m <br /> OWNER NAME Affordable Luxury Home PHONE 209-481-8861 H <br /> OWNER ADDRESS 5711 N.EI Dorado Street CITY/STATEZP Stockton,CA 95207 <br /> CONTRACTOR Krazan&Associates.Inc. PHONE 5`19.348.2200 <br /> CONTRACTOR ADDRESS 215 W.Dakota Avenue CITYISTATE/LP Clovis,California 93612 <br /> SUBCONTRACTOR Krazan&Associates;Inc PHONE 559.348.2200 <br /> SUBCONTRACTOR ADDRESS 215 W.Dakota Avenue CITY/STATE/LP Clovis.California 93612 <br /> LICENSE -/C-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 USE Domestic/Private 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 New Well Replacement Well Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells Soil Boring(s) #of borings �J Geotechnical 5 #of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair (10-15 Feet) <br /> New Pump Pump Replacement 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 10-f J ft Excavation in diameter I Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Weil Casing Diameter_in Thickness/Gauge/ASTM Schad Steel i Plastic Stainless Steel Other <br /> Grout Seal Depth I Q-15' It //Neat Cement(94 Ib bag/5-10 gal water) Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width It Length ft Thick in Christy Box Stove Pipe <br /> PUMP Submersible Turbine Other HP Pump Set___It 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 H CE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED t A TITLE Managing Engineer DATE 03/31/2020 <br /> YMF <br /> O <br /> ?p?0 <br /> co <br /> FNr <br /> DEPARTMENT USE ONLY 7y <br /> Application Accepted By `— Date Z Area ) 5/Ji.IL�J Employee ID# <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By -I,' Date p WAIVER Received <br /> Soil Boring Inspection By� _V u Date ,�c Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Chec Amount Date Permit/ Invoice# Well ID# <br /> Codes Info Remitted Service Re uest# <br /> EHD 43-06 revised 4/14/18 WELL/PUMP PERMIT <br />