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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 Central Parkway at Mustang Way ,;IF lif V CITYIZIP Mountain House,CA m <br /> t/ � o <br /> CROSS STREET APN d-S y a q 8 J.PARCEL SIZE ',�J LAND USE APPLICATION* p <br /> m <br /> OWNER NAME CATX Partners LLC PHONE 408-666-3743 in <br /> OWNER ADDRESS 5875 Assist Ct CITY/STATI San Jose,CA 95138 <br /> CONTRACTOR Krazan$ASSociates.Inc. PHONE 559 348.2201) <br /> CONTRACTOR ADDRESS 215 W.Dakota Avenue CITYtSTATEIZIP f,lovis,California 93612 <br /> SUBCONTRACTOR <br /> Krazan 8 Assoelales,Inc PHONE 559.348.2200 <br /> SUBCONTRACTOR ADDRESS 215 W Dakota Av-nue CITYISTATE/ZIP Clovis.Califnmia 93612 <br /> LICENSE JC-57 C-61 D-09 Othef NUMBER _1i1�Ii�l�t E%PIRATION DATE 10:31/2020 <br /> DOMESTIC WELL SAMPUNG: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE U Domestic[Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> D Public Water System <br /> If diferenl from Owner Wale,System Name Conrad Name or Phone Number <br /> TYPE OF WORK D New Well Replacement Well I Well Alteration/Modification Other <br /> Monitoring Well(s) B of wells Soil Bonng(s) X of borings V Geotechnical B 9 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 Casio <br /> WELL CONSTRUCTION <br /> Drilling Method L Mud Rotary Air Rotary //Auger Cable Tool Push Point Other <br /> Proposed Well Depth I L) •�7 ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> C 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 Depth j,'] -S:) It ./Neat Cement(94 Ib bagI 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 Instilled By Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions.VVldlh ft Length ft Thick in Christy Box Stove Pipe <br /> PUMP Submersible Turbine Other HP Pump Set ft Standing Water Level It <br /> 1 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 HOU VA E NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> TITLE Managmg Engineer DATE 03/31/2020 <br /> SIGNED <br /> E�MENTI <br /> PR 02 <br /> J gQUIIy COU'Vry <br /> OEpARTMFNT <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date ��,l Area y- t Employee IDx 5�< <br /> Grout Inspection By Date F1 SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC I Received ChecliI Amount Date Permit/ Invoice B Well IDB <br /> Codes Info Remitted a ice Re uest B <br /> L 7, SJ <br /> EHC 43-M revised 4114,18 'NE-L'PI,MP PERMIT <br />