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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 />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 2y0111 W. r. Mcir+-o i -c tbe✓ K ,� /z5u• CITY/ZIP Stockton, CA <br />CROSS STREET / ici 0 Is -0)1 APN '7 � I 70 b PARCEL SIZE. d3 LAND USE APPLICATION # <br />OWNERNAME Rosana Holdings, LLC <br />OWNER ADDRESS 25 East Airways Blvd CITY/STATE/ZIP Livermore, CA <br />CONTRACTOR Krazan & Associates, Inc. PHONE 559-348-2200 <br />CONTRACTOR ADDRESS 215 W. Dakota Avenue CITY/STATEIZIP Clovis, CA 93612 <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br />LICENSE X C-57 -- C-61 - D-09 - Other NUMBER 499908 EXPIRATION DATE 10/31/2022 <br />DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (439 1) ❑ 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 - Replacement Well Well Alteration/Modification - Other <br />Monitoring Well(s) # of wells - Soil Boring(s) # of borings X Geotechnical 3 # of borings <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 />WELL CONSTRUCTION <br />Drilling Method - Mud Rotary Air Rotary - Auger Cable Tool - Push Point Other <br />Proposed Well Depth i D - S") ft Excavation in diameter - Open Bottom - Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter ! Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched - Steel - Plastic - Stainless Steel - Other <br />Grout Seal Depth -A -L) - J ft X Neat Cement (94 lb bagl5-10 gal water) - Sand Cement sack P"lVr <br />Bentonite (20% solids) = Other RECEIVED <br />Grout Placement Method - Pumped - Free Fall - Other - Retardant / Accelerator (name) <br />PEDESTAL Installed By - Driller - Pump Contractor _ Other <br />Concrete Pedestal -Dimensions: Width ft Length ft Thick SAN JOAQUIN COUNTY <br />in - Christy Box Stove Pipe 14rAITH <br />ENVIRONMENTALNI <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 />MININ111 Nt 24 110t'R ADVANCI: AOTIC[: REQUIRED 1�01R INSPL('TIONS - PLEASE ('ALL (209) 953-7697 <br />DEPARTMENT USE ONLY // <br />Application Accepted By �� . -Date Area 'etD'. <roY1 Employee ID# IM, <br />Grout Inspection By Date Z ZZ ❑ SPECIAL Well Permit <br />Pump Inspection By Date ❑ WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />PE <br />Codes <br />SC Received Check#/ <br />Info Cash <br />Amount Date Permit/ Invoice # Well ID# <br />Remitted rvice Req est # <br />EHD043-06 10i25!2021 Page I uf' Well: Puny' Peruut <br />