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a <br />WELL/PUMP PERMIT <br />SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT GALL (ZU9) 9b3 -/69l FOR INSPECTIONS txPIKt=S l TEAR FROM <br />Joe AoDREss ? 10q <br />/ / Vermillion Drive Cm!/ZIPStockton, CA <br />CROSS STREET R%Z& Crce1< / "T 4t APN i 74S' Z O3 � PARC�EL SIZE �LAND USE APPLICATION #_ <br />OWNER NAME Delta Community Developers Corp '",$r.)�C 0,)vs:; P� /i C t k or;V PHON209-460-5042 <br />OWNER ADDRESs2575 Grand Canal Blvd crrYiSTATWZ;tockton, CA 95207 <br />CONTRACTOR Krazan & Associates, Inc. <br />CONTRACTOR ADDRESS 215 W. Dakota Avenue <br />SUBCONTRACTOR Krazan & Associates. Inc. <br />SUBCONTRACTOR ADDREss 215 W. Dakota Avenue <br />LICENSE /C-57 - C-61 D-09 - Other <br />PHONE 659.348.2200 <br />CITY/STATFJZiPCiovis, California 93612 <br />PHONE 559.348.2200 <br />CrryISTATE/ZIPCiovis, California 93612 <br />NUMBER 499908 EXPIRATION DATE 10.31.2021 <br />DOMESTIC WELL SAMPLING: C General Mineral/Coliform Bacteria (4391) - Dibromochloropropene (4392) Arsenic (4393) <br />INTENDED USE Domestic/Private - Irrigation/Agricultural - Industrial C- Water Quality Monitoring - Soil Sampling/Characterization <br />C Public Water System <br />If different from Owner: Water System Name Contact Name ar 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 �[ Geotechnical 1 #or borings <br />- Out -Of -Service Well Out -Of -Service Well Renewal C Cross -Connection Repair (25 Feet) <br />- New Pump Pump Replacement -- Pump Repair - Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method - Mud Rotary - Air Rotary 4 Auger = Cable Tool - Push Paint - Other <br />Proposed Well Depth 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 Schad Steel Plastic - Stainless Steel - Other <br />Grout Seal Depth It Neat Cement (94 lb bag6-10 gal water) - Sand Cement sack mix17 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 It 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. 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 />O <br />m <br />DEPARTMENT USE ONLY 1 <br />Application Accepted By Data r3 / Area / s /� �y''' Employee ID# <br />Grout Inspection By Date �Z) —SPECIAL Well Permit <br />Pump Inspection By Date — WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />EH043-M revised 4/14/18 WELL/PUMP PERMIT <br />MFNT <br />QED <br />` 2421 <br />co <br />NTq�NTY <br />T MFNT <br />car � •►i�;.����t�nE���c���nmr►.ryn�:�����■ <br />EH043-M revised 4/14/18 WELL/PUMP PERMIT <br />MFNT <br />QED <br />` 2421 <br />co <br />NTq�NTY <br />T MFNT <br />