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I WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />rYLJIY-KtFUNUAtiLE h'ERMIT UALL -LUy y03-1by7 FOR INSPECTIONS EXPIRE -5 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 105 Northgate Drive CITYILP Manteca, CA <br />v' <br />CROSS STREET / i i'� APN i� 00 PARCEL SIZE 03 LAND USE APPUCAT10N # <br />OWNER NAME Standard Plumbing SupplylgeeS':� R,,J C L,fF s 1rves4w :,1 PHONE <br />OWNER ADDRESS 105 Northgate Drivel P p 6 Off( 7Dell (10 CITY/STATE/ZIP Manteca, CA <br />CONTRACTOR Krazan & Associates, Inc <br />CONTRACTOR ADDRESS 215 W. Dakota Avenue <br />SUBCONTRACTOR Krazan & Associates, Inc. <br />SUBCONTRACTOR ADDRESS 215 W. Dakota Avenue <br />LICENSE X C-57 C-61 0-09 Other <br />PHONE 559-348-2200 <br />CITY/STATEIZIP Clovis, CA 93612 <br />559-348-2200 <br />PHONE <br />CITY/STATE1ZIPClovis, CA 93612 <br />NUMBER499908 EXPIRATION DATE 10.31.2022 <br />DOMESTIC 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 <br />New Well Replacement Well Well AlteratiorUModification <br />Other <br />Monitoring Well(s) # of wells Soil Borings) s Of borings X Geotechnical 2 s of borings <br />Out -Of -Service Well Out -Of -Service Well Renewal <br />Cross -Connection Repair (10-50 Feet) <br />P <br />New Pump Pump Replacement Pump Repair <br />Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method <br />Mud Rotary Air Rotary Auger Cable Tool Push Point <br />Other <br />Proposed Well <br />Depth ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size <br />n lameter <br />Conductor Casing in diameter I Conductor Casing Depth <br />ft <br />S <br />Well Casing <br />Diameter _ in Thickness/Gauge/ASTM Sched Steel <br />, Plastic Stainless Steel l rJ <br />Grout Seal <br />Depth :J- -> ft X Neat Cement (94 Ib bag/5-10 gal water) <br />Sand Cement ATF i <br />wrd�r <br />Bentonite (20% solids) Other <br />7_11 <br />Mh�pl <br />n�� F /T <br />Grout Placement Method Pumped Free Fall Other Retardant <br />/ Accelerator (name) <br />�� <br />PEDESTAL Installed By Driller Pump Contractor Other <br />Concrete Pedestal Dimensions: Width ft Length ft Thick <br />n Christy Box Stove Pipe <br />Pump Submersible Turbine , Other HP Pump Set ft Standing Water Level ft <br />Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect to the following items: GPS <br />Coordinates, property lines, adjoining properties, water bodies or courses, drainage pattern, roads, existing wells, structures, <br />potential sources of contamination, sewers or private disposal systems. Include distance from two property lines. For Domestic, <br />Agriculture, Industrial well, provide location of any water wells or surface water within 200' radius of proposed well. <br />111\INIt'%1 24 11011 R .0 N ANCF. NO Itch: RBQI lwil) 1.014 INSPI(CI IONS - I'LF:%SF: C%IA. (207) 9;3-7677 <br />DEPARTMENT USE ONLY <br />Application Accepted By �i`�—L�L� Date /D <br />Grout Inspection By Date <br />Pump Inspection By Date �/� <br />Soil Boring Inspection By_ Date Gt/ <br />COMMENTS C3l�s L C F Ll AGL C1JCnS <br />Area /�G,'Yt�r« ' Employee ID# <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth <br />Ci,: <br />ft <br />N <br />D <br />�n <br />N <br />L <br />rT <br />D <br />PE Sc Received hec <br />Codes Info B <br />Amount Date Permit/ Invoice # Well ID# <br />Remitted Seryice R ues # <br />i' <br />EHI)NO.06 10.'252021 Page I of: l%zIl Punk Perm�i <br />