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WELL/PUMP <br />SC <br />Info <br />PERMIT <br />eck#! <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTfIENT <br />Date <br />1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - <br />(209) 468.3420 <br />N -REFUNDABLE PERMIT <br />ADDRESS 1540 2nd Street <br />CONTRACTOR Krazan &Associates, Inc. <br />CONTRACTOR ADDRESS 215 W. Dakota Avenue <br />SUBCONTRACTOR Krazan & Associates, Inc. <br />I:ALL ("LU`JI 9b3-/69/FOR INSPECTIONS <br />SUBCONTRACTOR ADDRESS 215 W. Dakota Avenue CITY/ST <br />LICENSE VC -57 ❑ C-61 ❑ D-09 ❑ Other NUMBER 499906 <br />�74G\C�i:i�lry��la\ti 61.1gi�l <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) ❑Arsenic (4393) <br />TYPE OF WORK ❑New Well ❑Replacement Well ❑Well AlteralionlModificetion ❑Other <br />❑ Monitoring Wells) # of wells ❑ Soil Boring(s) # ofbodngs Vj Geotechnical 2 # of borings <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair (20-50 Feet) <br />o New Pum a Pum Replacement El Pump Repair 11 Raise Well Casing <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 />NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209) 953-7697 <br />/r TITLE Managing Engineer DATE 11/12/2020 <br />T <br />TM�NT <br />DEPARTMENT USE ONLY <br />Application Accepted By j—r`— G- �-- Date t t a S- � �%,�,� <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring <br />COMMENTS_ <br />Date <br />Hata <br />Area � � �� Employee ID# <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />PE <br />Codes <br />EHD 43-e6 revised 4/14/18 WELL /PUMP PERMIT <br />SC <br />Info <br />Received <br />eck#! <br />Amount <br />Remitted <br />Date <br />WELL CONSTRUCTION <br />We111D# <br />Drilling Method <br />L Mud Rotary ❑ Air Rotary Auger ❑ <br />Cable Tool ❑ Push Point I Other <br />Proposed Well <br />Depth 2 0 � O it Excavation <br />in diameter ❑ <br />Open Bottom L Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter ! <br />Conductor Casing Depth ft <br />Well Casing <br />Diameter _ in Thickness/Gauge/ASTM Schad ❑ <br />Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal <br />Depth 010 55-0 ft V Neat Cement (94 <br />lb bag15-10 gal water) <br />❑ Sand Cement sack mix/7 gal water <br />Li Bentonite (20% solids) ❑ Other <br />Grout Placement Method j(Pumped Q( Free Fall ❑ Other <br />❑ <br />Retardant /Accelerator (name) <br />PEDESTAL <br />Installed By ❑ Driller ❑ Pump Contractor <br />a Other <br />L Concrete Pedestal ❑Dimensions: Width <br />ft Length <br />ItThick in n Christy Box ❑ Stove Pipe <br />PUMP <br />❑ Submersible[] Turbine ❑ Other <br />HP <br />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 />NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209) 953-7697 <br />/r TITLE Managing Engineer DATE 11/12/2020 <br />T <br />TM�NT <br />DEPARTMENT USE ONLY <br />Application Accepted By j—r`— G- �-- Date t t a S- � �%,�,� <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring <br />COMMENTS_ <br />Date <br />Hata <br />Area � � �� Employee ID# <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />PE <br />Codes <br />EHD 43-e6 revised 4/14/18 WELL /PUMP PERMIT <br />SC <br />Info <br />Received <br />eck#! <br />Amount <br />Remitted <br />Date <br />PennlU <br />Sery a Re uest# <br />Invoice# <br />We111D# <br />