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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-PFFuniciABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED , . i , , <br />JOB ADDrs.ss Budiselich Road — . i(-)3 1 IlL,CA /Se I IC, VI crrya,p Stockton, CA <br />CROSS STREET 14114 Y q (2/t APN I OiCli OOLI PARCEL SIZE Li €616LAN. USE APPUCATION # <br />OWNER NAME BREGID, LLC PHONE 661-703-8402 <br />OWNER ADDRESS 2005 Howard Smith Avenue East CITY/STATE/ZIPWindsor, CO 80550 <br />razan & Associates. Inc. CONTRACTOR K PHONE 559'348220{l <br />CONTRACTOR ADDRESS 215W. Dakota Avenue CITY/STATE/ZIP Clovis. California 93612 <br /> <br />Kri,70.3 ' SUBCONTRACTOR & Associates Inc PHONE 4 50 348 2200 ' - . ' - <br />SUBCONTRACTOR ADDRESS 215W. Dakota Avenue WY/STATE/ZIP Clovis, Calliornia 93612 <br />LICENSE C-57 7 C-61 = D-09 = Other NUMBER 499908 EXPIRATION DATE 10.312021 <br />DOMESTIC WELL SAMPLING: = General Mineral/Coliform Bacteria (4391) : Dibromochloropropane (4392)1 Arsenic (4393) <br />INTENDED USE = Domestic/Private I: Irrigation!Agricultural = Industrial = Water Quality Monitoring = Soil Sampling/Characterization <br />= Public Water System <br />1 if different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK = New Well '1- Replacement Well = Well Alteration/Modification = Other <br />= Monitoring Well(s) if of wells 7 Soil Boring(s) trot borings 1 Geotechnical 4 #01 borings <br />= Out-Of-Service Well = Out-Of-Service Well Renewal = Cross-Connection Repair (20 to 50 Feet) <br />New Pump = Pump Replacement = Pump Repair 7 Raise Well Casing <br />I WELL CONSTRUCTION <br />Drilling Method 7 Mud Rotary I: Air Rotary Ni Auger = Cable Tool :Push Point = 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 Sched = Steel = Plastic = Stainless Steel = Other _ _ _ <br />Grout Seal Depth ft viNeat Cement (94 lb bag/5-10 gal water) :- Sand Cement sack mix/7 gal water <br />7 Bentonite (20% solids) = Other <br />Grout Placement Method = Pumped = Free Fall = Other =. Retardant / Accelerator (name) <br />PEDESTAL Installed By 1 Driller = Pump Contractor = Other <br />'. Concrete Pedestal =Dimensions: Width ft Length ft Thick in = Christy Box I Stove Pipe <br />PUMP = Submer4ible= Turbine I 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 />M 48 HOisi* .V" • • : i. • 4# REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED - Tim, Managing Engineer DATE 01/20/2021 _.....- <br />I Elligl.l.ronigill 11111 <br />hi.- Call aaa aiiaaauaa <br />44 111 11 I- I <br />f <br />1 <br />II; , I N I i • ii_ <br />II <br /> <br />aa•uaaaaaaa <br />ama RIM aa , am m ama a EL =Nu i <br />DEPARTMENT USE ONLY <br /> <br />Application Accepted By ..--.../---4 Date 60 Vol i <br />Grout Inspection By igejf„: SCA) at,S.C.. P412 r.- Date linik_I-J_ i SPECIAL Well Permit <br /> <br />Pump Inspection By Date .i WAIVER Received <br /> <br />Soil Boring Inspection By Date Constructed Well Depth <br />COMMENTS <br />PE <br />Codes <br />SC <br />Into <br />Received <br />i,' 12 <br />Checlaff Amount <br />Cash •emitted ,Da Permit! Invoice # Well ID# <br />1137472±_t ,S- 0 ROI twil # <br />' I' Ig <br />Siaji e u st # :SS300V 311S Area qhq Employee ID# <br />ft <br />EH() 43-06 revised 4/14118 WELL /PUMP PERMIT