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JOB ADDRESS 1527 S. Airport Way ciryfzip Manteca, CA <br /> <br />CROSS STREET Airport Way & Atherton APN 'II 0?(:) PARCEL SIZE ) LOLAND USE APPLICATION # <br />Dutch Bros <br />110 S W 4th Street <br />CITY/STATE/ZIP <br />Grant Pass, OR 97526 <br />Krazan & Associates, Inc <br />215 W Dakota Avenue CONTRACTOR ADDRESS <br />N/A <br />SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> <br />LICENSE X C-57 C-61 0-09 _ Other NUMBER 499908 <br />10/31/2022 <br />EXPIRATION DATE <br />OWNER NAME <br />OWNER ADDRESS <br />CONTRACTOR <br />SUBCONTRACTOR <br />559-348-2200 <br /> PHONE <br />CITY/STATE/ZIP Clovis, CA 93612 <br />PHONE <br />PHONE <br />I WELLJPUMP 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 />DOMESTIC WELL SAMPLING: 0 General Mineral/Coliforrn Bacteria (4391) 0 Dibromochloropropane (4392) 0 Arsenic (4393) <br />INTENDED USE Domestic/Private - Irrigation/Agricultural Industrial 7 Water Quality Monitoring <br />Public Water System <br />If different from Owner Water System Name <br />Soil Sampling/Characterization <br />Contact Name or Phone Number <br />- New Well <br /> Replacement Well 1 Well Alteration/Modification Other <br />- Monitoring Well(s) # of wells i_i Soil Boring(s) X of borings X Geotechnicai 5 X of borings <br />Out-Of-Service Well C.' Out-Of-Service Well Renewal Cross-Connection Repair (10-50 Feet) <br />_. New Pump i , Pump Replacement CT Pump Repair _ Raise Well Casing <br />TYPE OF WORK <br />WELL CONSTRUCTION <br />Drilling Method <br />Proposed Well <br />Well Casing <br />Grout Seal <br />_ Mud Rotary _ Air Rotary - Auger Cable Tool Push Point <br />Depth i 3 - ... ft Excavation in diameter <br />_ Conductor Casing in diameter / Conductor Casing Depth <br />Diameter in Thickness/GaugeJASTM Sched . Steel -i Plastic Stainless Steel _ Other <br />Depth ,..) • ii ft X Neat Cement (94 lb bag/5-10 gal water) Sand Cement <br />Bentonite (20% solids) II Other <br />Open Bottom <br />X Other 1-follow Stern Auger <br />- Gravel Pack/Gravel Size in diameter <br />ft <br />sack mix17 gal water <br />Retardant / Accelerator (name) PAY NI ENT <br />PEDESTAL Installed By I Driller - Pump Contractor Other Rt. CEIV ED <br />Concrete Pedestal _ Dimensions: Width ft Length <br />in _ Christy Box Stove Pipe <br />HP Pump Set ft Standing Witeri,Lftwejcour_ ft <br />Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect to the fpkiiitatir4 ittS: 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 />NIIN I Nit NI 24 1101 R MANCE NOTICE REQ1 IRLI) OR INSPE( TIONS I; ktii: ( NI I (209) 953-7697 <br />DEPARTMENT USE ONLY <br />Application Accepted By Date 2/30/dd Area 3frat.,.:41'C ('' Employee ID# <br />Grout Inspection By Date 0 SPECIAL Well Permit <br />Pump Inspection By Date 0 WAIVER Received <br />Date gilA 040 7-02-z- Constructed Well Depth ft <br />iL.Li .:;Pel ii r-,/,. epf"'" t Pe; II 3D ( iL,. e, }- ra r - 0; ...,„r(l ,,,, <br />PE <br />Codes <br />SC <br />Info <br />Received <br />B <br />Check*/ <br />Cash <br />Amount <br />Remitted Date PermiV <br />Service Request # Invoice # Well ID# <br />'-I3 70 1.-T' .3s2c14- 4aocii 1•2-N1— iNipoo-t1-1144 <br />Grout Placement Method Pumped _ Free Fall 11 Other <br />ft Thick <br />FEB 232022 <br />PUMP Submersible: Turbine _ Other <br />Soil Boring Inspection By ,-• <br />COMMENTS f ery) f <br />C.::,)11-ta re.C1 :SSMIOGY 311S El 0)043-06 10 75 2021 Well t Pump Permit