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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 /> Joe ADDRESS 2895 North Naglee Road CITYIZIP Tracy,CA m <br /> J y� �'�[� LJ a <br /> CROSS STREET P"—V i t It7•1 APN 17112d CI�/`��! PARCEL SIZE 4r I LAND USE APPLICATION# A <br /> OWNER NAME JToryota I flit y �`1 I J L.9 r1G/ L L PHONE <br /> OWNER ADDRES 4(,7S SN-veirls Creek sl\'o 12S' CITYISTATE/ZIP.15 C:Vt kl C IC.:rA 'I 570`y ' <br /> CONTRACTOR Krazan&Associates.Inc. PHONE 559 34$.2200 <br /> CONTRACTOR ADDRESS 21.5 W.Dakota Avenue CITY/STATE/ZIP Clovis,California 93612 <br /> SUBCONTRACTOR Krazan&Associates,Inc. PHONE 559.348.2200 <br /> SUBCONTRACTOR ADDRESS 21,5 W Dakota Avenrle CITY/STATEIZJP Clovis.California 93612 <br /> LICENSE VC-57 C-61 D-09 Other NUMBER 44)9908 EXPIRATION DATE 1U^312020 <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> r!!!!sE Domestic/Privale Inigation/Agricultural Industrial Water Quality Monitoring /Sail 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 f Geotechnical 3 #of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair 15-50 Feet) <br /> New Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method i Mud Rotary Air Rotary y/!Auger Cable Tool Push Point Other <br /> Proposed Well Depth )S-50 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 )'S'S ft of Neat Cement(94 111 bag/5-10 gal water) Sand Cement sack mtx/7 gal water <br /> Bentonite(20%solids) i Other <br /> Grout Placement Method . Pumped Free Fall Other Retardant/Accelerator(name) <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.11 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 r ADVAbICE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED <br /> TITLE Managing Engineer DATE 09/23/2020 <br /> C�Ie/V <br /> F/QED <br /> FYI <br /> T 4 ?420 <br /> I <br /> FP4 AUNTY <br /> MENT <br /> i <br /> DEPARTMENT U E ONLY !►' r <br /> Application Accepted By Z— _ Date 3 V� � � Area � I r�A� Employee ID# D <br /> Grout Inspection By Date SPECIA Well Permit <br /> Pump Inspection By _ Date F WAIVER Received <br /> Soil Barin Inspection By nato /r �•.,^.e.werr ne .r <br /> CQ....rsrrc Spm�Q �. J » �'FI. f11 V,IC F 3,j to- .3O 1 fl'�- 1(M (!�F'prL� <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info Remitted Semice Request# <br /> 37d S60 <br /> EMD 43-06 revised 4114/18 WELL/PUMP PERMrf <br />