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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 /> to <br /> JOB ADDRESS 305 Gandy Dancer Drive CITY/ZIP Tracy.CA m <br /> D <br /> CROSS STREET Tracy Boulevard APN PARCEL SIZE LAND USE APPLICATION# z <br /> m <br /> OWNER NAME Madruga Iron Works PHONE 209-832-7003 y <br /> OWNER ADDRESS 305 Gandy Dancer Drive CITY/STATE/ZIP Tracy.CA <br /> CONTRACTOR Krazan&Associates.Inc. PHONE 559.3482'2..00 <br /> CONTRACTOR ADDRESS 215 W.Dakota Avenue CITY/STATE/ZJP Clovis,California 93612 <br /> SUBCONTRACTOR Krazan&Associates,Inc. PHONE 559.348.2200 <br /> SUBCONTRACTOR ADDRESS 215W Dakota Avenue CITY/STATE/7jP Clovis.California 93612 <br /> LICENSE fC-57 C-61 D-09 Other NUMBER 499908 EXPIRATION DATE 10.312020 <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE DomesticfPrivate 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 �/Geotechnical 3 #of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair ')-t)u Feet) <br /> New Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary V Auger Cable Tool Push Point Other <br /> Proposed Well Depth 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 ickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br /> Grout Seal Depth /Neat Cement(941b b g/5-10 al water) Sand Ceme t sack mixl7 gal water <br /> Bentonite(20%solids) Other A l/ / 1 G s <br /> Grout Placement Method Pumped Free Fall Other Retardan Accelerator(name) LAj r <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width ft Length ft Thick in Christy Box 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 L WS. <br /> MINIMUM 48 AD CE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TLE Managing Engineer DATE 05/1312020 <br /> IVNT <br /> Ep <br /> 414 1 202p <br /> A <br /> Vlql CoL/NrY <br /> E NTAL <br /> TMENT <br /> ttl <br /> DE,P ,ATMENT USE ONLY <br /> Application Accepted ByJJN� YT-14 Date O�d Area!�Vfftf4 Employee]D# s� <br /> Grout Inspection By Dale SPECIA Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection ByNdjuicm Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Chec Amount Date Permit/ Invoice# Well ID# <br /> Codes Info ash Remitted Service Re uest# <br /> -476Q -51njA [4U 0220 <br /> EHD 43-06 revised 4/14118 WELL/PUMP PERMIT <br /> .1 <br />