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e <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 /> I JOB ADDRESS 295 West Mathews Road CITYfzIP French Camp,CA <br /> CROSS STREET A-Y1 APNV <br /> __L9 �TTy�uf—PARRpCCEEL SIZE �'`� LAND USE APPLICATION <br /> I!OWNER NAME _s� s1�/oc V) oyyl�y PHONE209-460-5042 <br /> OWNER ADDRESs2575 Grand Canal Blvd _ — CITY/STATE2IF tOCkton,CA 95207 E <br /> CONTRACTOR Krazan&Associates Inc. PHONE 559.W8.2200 <br /> 'CONTRACTOR ADDRESS 2`16W.Dakota Avenue CITYISTATEIZIP Clovis.California 93612 <br /> SUBCONTRACTOR Krazan&Associates.Inc. PHONE 559346.2200 �- <br /> SUBCONTRACTOR ADDRESS 216 W Dakota Avenue CRvISTATE21P Clovis,California 93612 ... - <br /> LICENSE J •199603 10.31.2021 <br /> C-57 =C�1 - D-09 -Other NUMBER EXPIRATION DATE ' <br /> DOMESTIC WELL SAMPLING:_General Mineral/Coliform Bacteria(4391)-Dibromochioropropane(4392)=Arsenic(4393) <br /> INTENDED USE DOmestiClPrivate - Irrigation/Agricultural -Industrial -Water Quality Monitoring Z Soil Sampling/Characterization <br /> -Public Water System _ —It different from Owner Water System Name Contact Name or Phase Number <br /> TYPE OF WORK New Well -Replacement Well Well Alteration/Modification -Other <br /> # <br /> Monitoring Wells)— #of wells =Soil Boringof borings <br /> Boring(s) -1 Geotechnical 5 — <br /> of beings <br /> - Out-Of-Service Well -Out-Of-Service Well Renewal -Cross-Connection Repair 10-50 Feet <br /> New Pump -Pump Replacement _Pump Repair — :: Raise Well Casing _ <br /> WELL CONSTRUCTION <br /> Drilling Method - Mud Rotary -Air Rotary /Auger _ Cable Tool Push Point - Other <br /> Proposed Weir Deptf-1n_sO ft Excavation. in diameter -Open Bottom - Gravel Pack/Gravel Sizein diameter <br /> Conductor Casing—___—in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Schad - Steel = Plastic -Stainless Steel -Other_ <br /> Grout Seal DepthIt //Neat Cement(941b bagr5-10 gal water) Sand Cement sack mix/7 gal water <br /> -Bentonite(20%solids) -- Other_ <br /> Grout Placement Method 7_ Pumped - Free Fail -Other - Retardant/Accelerator(name) <br /> :PEDESTAL Installed By Driller - Pump Contractor _ Other _ <br /> Concrete Pedestal-Dimensions:Width ft Length ft ThicK in =Chnsty Box - Stove Pipe <br /> PUMP Submersible-Turbine - Other—. _ HP _ Pump Set—`_ft Standing Water Levet ft <br /> I HEREBY CERTIFY THAT 1 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 /> MINIMUM 48 U DYMCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE Managing Engineer DATE 01/15/2021 1 <br /> -41i <br /> E�Nr <br /> _ SFO <br /> ? ?0?1 <br /> fit <br /> -/V� <br /> - R��NTY <br /> _ _ I <br /> I <br /> D E P A R T M E N r USE ONLY <br /> Application Accepted By L ��'� _.= Date f Qh Area I _— EmployeelD# JUU 5- <br /> Grout Inspection By_1/71) .— Date ` SPECIAL Well Permit <br /> Pump Inspection By_ — Date WAIVER Received <br /> Soil Boring Inspection By —_,— Date Constructed Well Depth ft <br /> COMMENTS <br /> --- <br /> —.. <br /> — Amount 1.. _..---..._._._..._._................._.................... .....__...._....__...—— _....... <br /> PE i SC Red Check PermiU <br /> Codes I Info Remitte T Date Service Request# invoice# Well ID# <br /> ceive <br /> -------— <br /> EHD 43.06 revised 411471E WELL 1PjMP PERMIT <br />