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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 INSPEC <br />JOB ADDRESS Vermillion Drive <br />CROSS STREET CT i�J �i`Pf;'. IC C APN J��' a j� PAR <br />OWNER NAME Delta Community Developers Corp •s S SL �-Du Yt � y <br />OWNER ADDREW2575 Grand Canal Blvd <br />,.,,,,�e„-'„e Krazan & Associates, Inc. <br />PARC <br />ADDRESS 215W. Dakota Avenue <br />'OR Krazan & Associates. Inc, <br />SUBCONTRACTOR ADDRESS 215 W. Dakota Avenue <br />1 PEAR FROM DATE <br />SIZE ! 1-3 LAND USE APPLICATION # <br />�°(,tr�%p4209-460-5042 <br />CRY S7 T of ckton, CA 95207 <br />PHONE 559.348.2200 <br />CRY7STATEM,Qlovis. California 93612 <br />PHONE 569.348.2200 <br />CRY/STATEIZIpClovis, California 93612 <br />LICENSE -/C-57499908 C-57 -'. C-61 '__ D-09 '- Other NUMBER EXPIRATION DATE 10.31.2021 <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE - Domestic/Private - Irrigation/Agricultural - Industrial - Water Quality Monitoring - Soil Sampling/Characterization <br />- Public Water System <br />If different from Ovmer. Water System Name Contact Name or Phone Number <br />TYPE OF WORK - New Well - Replacement Well - WellAfteration/Modification C Other <br />MonitoringWell(s) #of wells .SoilBoring(s) #ofborings Geotechnical 1 #of borings <br />Out -Of -Service Well 7 Out -Of -Service Well Renewal Cross -Connection Repair (25 Feet) <br />New PumD C PumD Replacement - Pump Repair ❑- Raise Well Casing <br />Drilling Method - Mud Rotary - Air Rotary Auger - Cable Tool - Push Point Other <br />Proposed Well Depth V�_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 `• ft Neat Cement (94 lb bag/5-10 gat water) Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method - Pumped - Free Fall = Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By C 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 />1 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 />D <br />A <br />A <br />DEPARTMENT USE ONLY <br />A <br />Application Accepted By Date � <br />� o Area Employee ID# _ <br />Grout Inspection By H Date L SPECIAL Well Permit <br />Pump Inspection By Date WAIVER Received <br />Solt Boring 1lEIns ton 8 Date Constructed Well De h ItCOMMENTS�I mita, /� t TD 64 �E� A''� ftr� hL WL"t try- `F�ML'e3, °�'F�Y—eIF <br />PE <br />Codes <br />Sc Received c <br />tufo as <br />Amours! <br />_ Remitted <br />Permit/Dat Invoice # Well ID# <br />rvice Request # <br />EH0 4&08 revised 4114118 WELL /PUMP PERMIT <br />ANT <br />FD <br />'02, <br />CNT y <br />LENT <br />