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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-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS Giro Stipp}. <br />ApN 259-18 CROSS STREET ICA -016 and 17 tie PARCEL SIZE I , ° LAND USE APPUCATION # <br />OWNER NAME Bethany Homes SQL 14,1), PHONE <br />930 W Main Street Ripon, CA 95366 W. OWNER ADDRESS CITY/STATE/ZIP <br />PHONE 559.348.2200 <br />Ripon,CITY/Zie CA <br />Krazan & Associates, Inc. CONTRACTOR <br />CONTRACTOR ADDRESS 215W, Dakota Avenue <br />SUBCONTRACTOR Krazan & Associates, Inc. <br />crryisTATETzip Clovis, California 93612 <br />PHONE 559'3482200 <br />SUBCONTRACTOR ADDRESS 215W. Dakota Avenue CITY/STATE/ZIP Clovis, California 93612 <br /> <br />= Submersible= Turbine = Other HP Pump Set ft Standing Water Level ft PUMP <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, Amp 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 />MINI 48 HO <br />SIGNED <br />DEPARTMENT USE ONLY <br /> <br />Application Accepted By ..-X 2_,„ Z__ Date SA .2.A? 1 Area g el Employee 10# <br /> <br />Grout Inspection By Date i SPECIAL Well Permit <br /> <br />Pump Inspection By Date i WAIVER Received <br /> <br />Soil Boring Inspection By Date % 1 ‘A ti..A Constructed Well Depth <br />COMMENTS <br />NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />TITLE Managing Engineer DATE 05/13/2021 <br />ft <br /> ATTA <br />PEDESTAL Installed By - Driller = Pump Contractor = Other <br />Concrete Pedestal =Dimensions: Width ft Length ft Thick in = Christy Box .= Stove Pipe <br />2 Monitoring Well(s) 11 of wells 7, Soil Boring(s) "b°6"9s Geotechnical 5 <br />= Out-Of-Service Well = Out-Of-Service Well Renewal Cross-Connection Repair 10-50 Feet <br />= New Pump .2 Pump Replacement - Pump Repair 2 Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method = Mud Rotary = Alr Rotary 4 Auger = Cable Tool = Push Point = Other <br />Proposed Well Depth it0—....)0 ft Excavation in diameter = Open Bottom 2 Gravel Pack/Gravel Size in diameter <br />2. Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched 2. Steel .2 Plastic = Stainless Steel = Other <br />Grout Seal Depth - ft N1 Neat Cement (94 lb bag/5-10 gal water) = Sand Cement <br />= Bentonite (20% solids) = Other <br />Grout Placement Method Z Pumped = Free Fall = Other Retardant / Accelerator (name) <br />sack mix/7 gal water <br />S ot borings <br />LICENSE VC-57 = C-61 = 0-09 = Other NUMBER 499908 EXPIRATION DATE 10.31.2022 <br />DomasTic 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 _7 Replacement Well Well Alteration/Modification 2 Other <br />PE <br />Codes <br />SC <br />Info <br />Received C.Sheckfike <br />---"Ursh <br />Amount <br />Remitted Date Permit/ <br />Service Request if Invoice* Well ID* <br />437,2 IS-0 3q-b)373 106L,i 9 2- 11 1 WFOOL4M4.1- <br />END 43-06 revised 4/14/15 WELL /PUMP PERMIT