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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 />NUN-KEFUNDABLE PERMIT GALL (LUU) y03 -/6y/ FOR INSPECTIONS tAYIKtb 7 YEAR FROM UATE ISSUED <br />JOB ADDRESS Oso Avenue and South Street <br />Cm/LP Tracy, CA <br />(/M�-t. <br />17 235-100-76 <br />C iy eel <br />� � <br />CROSS STREET .S 1 APN <br />PARCEL SIZE& to LAND USE APPLICATION # <br />OWNER NAME SIST3RS, Inc <br />PHONE <br />3613 Plaudit Drive <br />Modesto, CA 95355 <br />OWNER ADDRESS <br />CITYISTATEIZIP <br />CONTRACTOR Krazan & Associates, Inc. <br />PHONE 559.348.2200 <br />CONTRACTOR ADDRESS 215 W. Dakota Avenue <br />CITY/STATE/ZIP Clovis, California 93612 <br />SUBCONTRACTOR Krazan & Associates, Inc, <br />PHONE 559.348.2200 <br />SUBCONTRACTOR ADDRESS 215 W. Dakota Avenue <br />CiITYISTATEMI, Clovis, California 93612 <br />LICENSE / C-57 - C-61 - D-09 - Other <br />NUMBER 499908 ExPIRATIoN DATE 10.31.2022 <br />DOMESTIC WELL SAMPLING: - General Mineral/Coliform Bacteria (4391) - Dibromochloropropane (4392) - Arsenic (4393) <br />NTENDED 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 />- Monitoring Well(s) # of wells - Soil Boring(s) # or borings Geolechnical 4 # of borings <br />- Out -Of -Service Well - Out -Of -Service Well Renewal - Cross -Connection Repair (10-50 feet) <br />' e rump _ rump rcnpmwrtlent _ rwnP rrtepau _mise even 1-1"51 <br />WELL CONSTRUCTION <br />Drilling Method - Mud Rotary - Air Rotary / Auger - Cable Tool - Push Point - Other <br />Proposed Well Depth Q ft Excavation in diameter - Open Bottom - Gravel Pack/Gravel Size in diameter <br />- Conductor Casing in diameter / Conductor Casing Depth It <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Schad - Steel - Plastic - Stainless Steel - Other <br />Grout Seal Depth J' 4� O It /Neat Cement (94 lb bag/5-10 gal water) - Sand Cement sack mix/7 gal water <br />- Bentonite (20% solids) - Other <br />Grout Placement Method - Pumped fJ( Free FallOther Ifw1 Y14 - 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 Levet 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 CALIFOgN[A-CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />MINIM HOU �OTICE REQUIRED FOR INSPECTIONS PLEASE CALL (209) 953-7697 <br />SIGNED - li TITLE Managing Engineer DATE 06/17/2021 <br />DEPARTMENT USE ONLY <br />r 1 � <br />Application Accepted By L � , Date F .Y 1 Area YL^e Employee ID# <br />Grout Inspection By Date - SPECIA Well Permit <br />Pump Inspection By Date WAIVER Received <br />Soil Boring Inspection By Date 9�"Y Constructed Well Depth It <br />COMMENTS <br />EHD 43-06 revised 4/14/18 <br />WELL /PUMP PERMIT <br />