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ca <br />A <br />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 />JOB ADDRESNO_ Moffat Boulevard and S. Garfield Avenue cirdzip Manteca, CA <br />CROSS STREET Ge: rr Ile id ApN aloLioN <br />PARCEL SIZE ,R -1 LAND USE APPUCATION # <br />OWNER NAME <br /> San Joaquin Regional Rail Commission PHONE <br />OWNER ADDRESS 949 E. Chanel Street <br />CITY/STATE/ZIP Stockton, CA <br />CONTRACTOR <br /> Krazan & Associates, Inc. PHONE 559.348.2200 <br />CONTRACTOR ADDRESS 215W. Dakota Avenue CITY/STATE/ZIP Clovis, California 93612 <br />SUBCONTRACTOR Krazan & Associates, Inc. PHONE 559.348.2200 <br />SUBCONTRACTOR ADDRESS 215W. Dakota Avenue Cm/STATE/Zip Clovis, California 93612 <br />LICENSE VC-57 = C-61 D-09 2 Other NUMBER 499908 EXPIRATION DATE 10.31.2022 <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 Owner. Water System Name Contact Name or Phone Number <br />TYPE OF WORK New Well = Replacement Well = Well Alteration/Modification = Other <br /> <br /># of wells = Soil Boring(s) #011)°"^gs Geotechnical 4 *of borings <br />= Out-Of-Service Well Renewal = Cross-Connection Repair (10-50 Feet) <br /> <br />Pump Replacement = Pump Repair = Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method = Mud Rotary = Air Rotary si Auger = Cable Tool = Push Point = Other <br />Proposed Well Depth 10 -S-3 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 10 —517, ft Nt Neat Cement (94 lb bag/5-10 gal water) Sand Cement sack mix I7 gal wale <br />= Bentonite (20% solids) = Other <br />Grout Placement Method = Pumped Free Fall 4 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, D RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE WITH THE CALIFORNIA NTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAW. - <br />H5(6- D E NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />Trru Managing Engineer DATE 114/22/21121 SIGNED <br />= Monitoring Well(s) <br />= Out-Of-Service Well <br />= New Pump <br />EE A TTA CH ED A <br /> P4 _ <br /> Af4r 4.J <br />/v/4/6j/IVC/1 <br />weNt. <br />DEPARTMENT SE NLY L Y .27 Area 6/P11114" Employee ID# <br /> <br />E SPECIAL Well Permit <br />E WAIVER Received <br />Constriucted Well Depth ft <br />ATV ther, CEPP} PPP'? r <br /> <br />,(Per Roe- f-u449/04g, ,6? <br />Application Accepted By <br />Grout Inspection By <br /> Inspection By <br />Date q <br />Date <br />Date <br />:Pc) <br />runup <br /> <br />Soil Boring Inspection By fl p TP IAPW.A <br />ate <br />k.itc,:v11-1 COMMENTS -r.t •irat• Sc r/s , 1 or <br /> <br />p%pe 411, be tzpej. /70 <br />PE <br />Codes <br />SC <br />Info <br />Received Check#/, <br />t..asn <br />Amount <br />Remitted <br />f Date Permit/ <br />Service Bequest # Invoice # <br />• <br />Well ID# <br />1137c2 I c0 ( 4 3ys?-1/3---4t i ha 5-3 •zi <br />EHD 43-06 revised 4/14/18 WELL /PUMP PERMIT