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WELL/PUMP PERMIT 7 <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 <br />CROSS STREET <br />OWNER NAME <br /> <br />18240 Harlan Road <br /> <br />CITY/ZIPLathrop, California <br /> <br />APN I Ciir r ) PARCEL SIZE I 4,721-AND USE APPLICATION # <br /> <br />In N Out Burger5 <br /> <br />PHONE 626-813-8275 <br /> <br />RE <br />UN <br />NVI ri <br />YNIENT <br />EIVE'D <br />N 2ü 2018 <br />ONIV1ENTAL <br />EPAR <br />UIN COUNTY <br />TMENT <br />OWNER ADDRESS 13502 Hamburger Lane <br />CONTRACTOR Krazan & Associates, Inc. <br />tripuCbriTytsTATE/zip Baldwin Park, CA 91706/if ow_ cij <br />PHONE 559.348.2200 <br />CONTRACTOR ADDRESS <br />215W. Dakota Avenue CITY/STATE/ZIP Clovis, CA 93612 <br /> <br />SUBCONTRACTOR <br /> <br />PHONE <br /> <br />SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br />LICENSE <br />499908 C-57 C-61 D-09 Other NUMBER EXPIRATION DATE 10/31/2018 <br />GEOGRAPHICAL INFORMATION: Coordinates X Township Range Section <br /> <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 /> <br />TYPE OF WORK New Well Replacement Well <br />Monitoring Well(s) # of wells <br />Out-Of-Service Well <br />New Pump Pump Replacement <br />Well Alteration/Modification Other <br />#01 borings z # of borings Soil Boring(s) v Geotechnical 2 <br />Out-Of-Service Well Renewal Cross-Connection Repair (10-50 Peet) <br />Pump Repair Raise Well Casing <br /> <br />WELL CONSTRUCTION <br />Drilling Method Mud Rotary Air Rotary VfAuger Cable Tool Push Point Other <br />Proposed Well Depthld •-•q1b1 ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />4% Well Casing Diameter in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br />(--...-,_ 0 Grout Seal Depth lp ..- .70 ft Vf Neat Cement (94/b bag/5-10 gal water) Sand Cement <br />Bentonite (20% solids) Other <br />Grout Placement Method Pumped Free Fall ,.0ther112.-(21.4 if,- <br />PEDESTAL Installed By Dnller Pump Contractor Other <br />Concrete Pedestal Dimensions: Width <br /> ft Length <br /> <br />ft Thick in Christy Box Stove Pipe <br /> <br />PUMP <br /> Submersible Turbine Other HP Pump Set ft Standing Water Level <br /> ft <br /> <br />in diameter <br />sack mod7 gal water <br />Retardant / Accelerator (name) <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 CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH <br />WORKERS COMPENSATION LAWS. <br />MINIMUM 24 H <br />SIGNED <br />...ADV - ED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />111111.19.- TITLE <br /> Managing Engineer DATE 06/18/2018 <br />. • <br />ENVIR <br />EALTH <br />2018 <br />TAI 1-011 TH <br />P WITISE CES RV1 <br />PA TMENT <br /> <br />Application Accepted By Date <br /> <br />Grout Inspection By Date <br /> <br />Pump Inspection By Date <br /> <br />Soil Boring Inspection By Date <br />COMMENTS <br />Area06-3 kr-7 Employee ID#A&fleti <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth <br /> ft <br />PE <br />Codes <br />SC <br />Info <br />Received <br />By <br />CCIml ..) Amount <br />Remitted Date Permit/ <br />Service Request # InvoicpEIMI <br />Cash <br />IfIli i 49- 333510 413/ 4-201Z 0 POO5gt--K2) <br />EXPIRE <br />ENO 43-06 <br /> WELL /PUMP PERMIT <br />4/3002