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PHONE <br />CROSS STFtEET .3-4 4k Tore. APN a s-qc,4, 073 PARCEL SIZE 49 I LAND USE APPLICATION # <br />Happy Daze RV <br />409908 EXPIRATION DATE 10.31.2022 LICENSE VC-57 T C-61 = 0-09 2 Other NUMBER <br />If different from Owner: Water System Name Contact Name or Phone Number <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 />JOB ADDRESS 1414 I Canal Drive cmazip Ripon, CA <br />1199 El Camino Avenue CITY/STATE/ZIPSacramento, CA OWNER ADDRESS <br />Krazan & Associates, Inc. 559.348.2200 CONTRACTOR PHONE <br />CONTRACTOR ADDRESS 215W. Dakota Avenue CITY/STATEIZip Clovis, California 93612 <br />OWNER NAME <br />SUBCONTRACTOR Krazan & Associates, Inc. PHONE 559'3482200 <br />SUBCONTRACTOR ADDRESS 215W. Dakota Avenue CITY/STATE/ZIP Clovis, California 93612 <br />DOMESTIC WELL SAMPLING: = General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) = Arsenic (4393) <br />INTENDED USE 2 Domestic/Private 2 Irrigation/Agricultural 2 Industrial 7 Water Quality Monitoring = Soil Sampling/Characterization <br />G Public Water System <br />WELL CONSTRUCTION <br />Drilling Method : Mud Rotary : Air Rotary Auger = Cable Tool _ Push Point Other <br />Proposed Well Depth 10-0) ft Excavation in diameter 2 Open Bottom = Gravel Pack/Gravel Size in diameter <br />: Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in ThicknessiGauge/ASTM Sched 2 Steel 2 Plastic Stainless Steel = Other <br />Grout Seal Depth I t5 ""VO ft ../ Neat Cement (94 lb bag/5-10 gal water) = Sand Cement <br />: Bentonite (20% solids) 7 Other <br />Grout Placement Method 7 Pumped )Free Fall A Other 4. feriwvfq. = Retardant / Accelerator (name) <br />sack mix17 gal water <br />WELL/PUMP PERMIT <br />TYPE OF WORK 7 New Well 7 Replacement Well 2 Well Alteration/Modification 2 Other <br />: Monitoring Well(s) # of wells = Soil Boring(s) " b'ing' si. Geotechnical 8 #01 borings <br />2 Out-Of-Service Well 2 Out-Of-Service Well Renewal = Cross-Connection Repair (10-50 Feet) <br />- Newt Pi imn - Purr,,, Renlarensent 7 Pump Renal, 7 Raise Well Casino <br />• <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. 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 />SIGNED <br />8 HOU <br />A <br />VIR cou <br />n&-Almivr NrY PAR 7.4;i4 L. <br /> <br />Application Accepted By <br />DEPARTMENT USE ONLY <br />Date Area al ‘ai'l Employee ID#11 6_ S12 tit 2 ) <br />Date SPECIAL Well Permit <br /> <br />Grout Inspection By <br />Date WAIVER Received <br /> <br />Pump Inspection By <br />4-26 ft Date Constructec Well Depth <br /> <br />Soil Boring Inspection By <br />ini el el' ento,,t.iltekezi o7"---diTel:Te2- A 5-r-ou COMMENTS -Trenimie p)re -10 by Ihrde <br />tlietin 30 AO'. <br />PE <br />Codes <br />SC <br />Info <br />Received ----cjoalet <br />Cash <br />Amount <br />Remitted att Permit/ <br />S ice • • uest # Invoice # Well ID# <br />LIL-7,2 150 5-41152 0 5f2A A . SD rti foe <br />CE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />TITLE Managing Engineer DATE 05/24/2021 <br /> <br />SA <br /> <br />fik;c1 <br />E-Air <br />202/ <br />EHD 43-06 revised 4/14118 WELL /PUMP PERMIT