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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 /> (A <br /> JOB ADDRESS Iw3 �� �� _ CITY/ZIP Stockton,CA m <br /> D <br /> CROSS STREET AMP r;tel N rG, APN ..7 /rY I`j�L PARCEL SIZE OL LAND USE APPLICATION# p <br /> m <br /> OWNER NAME KIPP Bay Area Public Schools PHONE 510-465-5477 m <br /> OWNER ADDRESS 1000 Broadway#460 CITY/STATE/ZIP Oakland,CA 94607 <br /> CONTRACTOR Krazan&Associates.Inc. PHONE 559.348.2200 <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 215W Dakota Avenue CITY/STATE/LP Clovis.California 93612 <br /> LICENSE JC-57 C-61 D-09 Other NUMBER 499908 EXPIRATION DATE 10.31 2018 <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Pnvate 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 Bodng(s) a of borings V Geotechnical 15 a of borings <br /> Out-Ot-Service Well Out-Of-Service Well Renewal Cross-Connection Repair (10-50 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 lJ-5 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 Depth I :+C1 ft V Neat Cement(941b bag/5-10 gal water) Sand Cement sack mixl7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped Free Fail Other 'Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width ft Length It 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 LAWS. <br /> MUM 4 U ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED ' TYLE Managing Engineer DATE 07/01/2020 <br /> IF-All <br /> F ANT <br /> l QED <br /> 02202 <br /> A Pi IF4 0 <br /> UlN <br /> E PMFN gjNTy <br /> ART MFNT <br /> I <br /> DEPARTMENT USE ONLY <br /> Application Accepted By ' �` Date '�`�"r O Area s/Oe' <+� Employee ID# DQ <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date 2 WAIVER Received <br /> Soil Boring C/Inspection By Date J Constructed Well Depth ft <br /> COMMENTS .,-I lit t?f imev'L6, St rnCj F'er-'rK sr. _14t1,?r1 007V <br /> PE SC 1 Received Chec Amount I Date PermiV Invoice# Well ID# <br /> Codes Info as Remitted i Service ReqpqAt <br /> 37.E Ise d$ 2U <br /> I <br /> I <br /> EHD 43-06 reweed"IV16 WELL/PUMP PERMIT <br />