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Ir <br /> 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 521 N.Wilma Avenue CITY/Zip Ripon, CA m <br /> CROSS STREET U �FS APN I C" PARCEL SIZE t V ' LAND USE APPLICATION# p <br /> m <br /> OWNER NAME Jeff Burrow PHONE 209-345-3434 to <br /> OWNER ADDRESS 2068 Fairway Oaks Drive CITY/STATE/zip Ripon, CA 95366 <br /> CONTRACTOR Krazan&Associates,Inc- PHONE 559 346.2200 <br /> CONTRACTOR ADDRESS 215 W.Dakota Avenue CITY/STATE/ZJP r>,viS,California 93612 <br /> SUBCONTRACTOR Krazan&Associates,Inc. PHONE 559348_`200 <br /> SUBCONTRACTOR ADDRESS 21.13W Dakota Avenue CITY/STATE/ZIP Clovis.California 93612 <br /> LICENSE VC-57 L_C-61 a D-09 i Other NUMBER 4y9908 EXPIRATION DATE 10.31.2020 <br /> DoMEsnc WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) 1 Arsenic(4393) <br /> INTENDED USE Domestic/Private 1 1 Irrigation/Agricultural i Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> i Public Water System <br /> If different from Owner: Water System"Jame Contact Name or Phone Number <br /> TYPE OF WORK I New Well , Replacement Well i Well Alteration/Modification Other <br /> I Monitoring Well(s) #of wells Soil Boring(S) #of borings V Geotechnical 5 of borings <br /> i Out-Of-Service Well F'Out-Of-Service Well Renewal Cross-Connection Repair (10-50 Feet) <br /> i New Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method !_i Mud Rotary A Air Rotary /Auger Cable Tool Push Point Other <br /> Proposed Well Depth 10'-SD ft Excavation in diameter i Open Bottom Gravel Pack/Gravel Size in diameter <br /> 5 Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched i Steel i Plastic i Stainless Steel Other <br /> Grout Seal Depthi��S l� ft .yr Neat Cement(94 Ib bag/5-10 gal water) i Sand Cement _sack mixt/gal water <br /> I Bentonite(20%solids) Other <br /> Grout Placement MethodA Pumped i Free Fall i Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller i Pump Contractor Other <br /> Concrete Pedestal i Dimensions:Width ft Length It Thick in Christy Box Stove Pipe <br /> PUMP I 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 /> MINIMUM 46 HO DVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED � � '� TITLE Managing Engineer DATE 09/05/2020 <br /> �+ MENT <br /> - - 1 14 EWED <br /> 2 1 2020 <br /> A AL SAN QUIN COUNTY <br /> ONMENTAL <br /> iENLrH DEPARTMENT <br /> / DEPARTMENT USE ONLY /7 <br /> Application Accepted By ��✓� Date /i� O&ADi Area /5 �� Employee ID# <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date n WAIVER Received <br /> Soil Boring Inspection By 31 WhAlIcDate V Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well IDN <br /> Codes Info A RYA Ipsh Remitted q.IK S <br /> y31,2 <br /> EHD 43-06 revised 4/14/10 4YELL HUMP PERMIT <br />