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r 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 ADDRESC 4715��EAy. tFopppiiano Lane crrytbP Stockton, CA <br />CROSS STREET MW <br />J - / In,APN o `FS3) O 1j 0' PARCEL SIZE LAND USE APPLICATION # <br />OWNER NAME Hindu Cultural Center _ PHONE 415-362-4937 <br />OWNERADDRESS 4715 E. Foppiano Lane CITY/STATE/ZIP Stockton, CA <br />CONTRACTOR Krazan & Associates, Inc. PHONE 659.346.2200 <br />CONTRACTOR ADDRESS 215 W. Dakota Avenue <br />SUBCONTRACTOR Krazan & Associates. Inc. <br />SUBCONTRACTOR ADDRESS 215 W, Dakota Avenue <br />CmlSrnrFJZIP Clovis, California 93612 <br />PHONE 559.3461200 <br />CITy1STATE21P Clovis, California 93612 <br />LICENSE /C-57 _ C-61 =. D-09 Other NUMBER 499906 EXPIRATION DATE 10.31.2022 <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropene (4392) Arsenic (4393) <br />INTENDED USE - Domestic/Private - IrrigationlAgricultural - 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 CC Well Alteration/Modification - Other <br />Monitoring Well(s) #of wells - Soil Boring(s) #at bonngs Geotechnical 2 #or borings <br />C <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 />Drilling Method Mud Rotary C Air Rotary 4 Auger Cable Tool C Push Point Other <br />Proposed Well Depth 10-:90 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 } D -TO ft Neat Cement (941b bagl5-10 gal water) = Sand Cement sack mW7 gal water <br />.=. Bentonite (20% solids) - Other <br />Grout Placement Method - Pumped - Free Fall - Other - Retardant / Accelerator (name) <br />PEDESTAL Installed By - Driller - Pump Contractor - Other _ <br />- Concrete Pedestal -Dimensions: Width it Length it Thick in - Christy Box - Stove Pipe <br />PUMP - SubmersibieC Turbine - Other HP Pump Set ft Standing Water Level ft <br />1 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 HOIR VjxiN E"1VOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED 1 4 TITLE Managing Engineer DATE 09/01/2021 <br />DEPARTMENT USE ONLY <br />C <br />Application Accepted By � � Date�_ Area � Employee ID# _7_v_ <br />Grout Inspection By Date ` SPECIAL Well Permit <br />Pump Inspection By Date WAIVER Received <br />Soil Boring Inspection By Date ( Constructed ell Depth it <br />COMMENTS Trerr�mll' D110P. tLL> If CrOi�1I[/V�1A GGeCI� f5 Pr1/.r�::�Br�(/ pY ,l7nL' IC <br />to <br />D <br />0 <br />m <br />E yMENT <br />CE�V�b <br />P 0 3 ?021 <br />4 QU/N <br />�ONM COUNT <br />°Epq R rMEN TY <br />PE <br />Codes <br />SC <br />Info <br />Received Chec --1 Amount a PermiU Invoice # Well 1W/ <br />ash Remitted ' ry ce Re ue t # <br />- <br />a <br />Iso <br />- ..- <br />-r <br />EHD 4308 revised 4114n8 WELL /PUMP PERMIT <br />