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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 />t'AI a 113n01 OR"1-7AQ7 FnR INSPECTIONS EXPIRES 'I YEAR FROM DATE ISSUED <br />NUN-McrUNUf1DLC f Gn�ru <br />JoB ADDRESS 17400 Golden Valley Parkwa <br />CROSS STREET & 1 Li. 1 APN 191-190-62 <br />OWNER NAME Golden Valley Parkway Investments — <br />OWNER ADDRESS <br />CONTRACTOR <br />4120 Dale Road J-8 #235 <br />Krazan & Associates, Inc. <br />CONTRACTOR ADDRESS 215 W. Dakota Avenue <br />SUBCONTRACTOR - <br />SUBCONTRACTOR ADDRESS <br />LICENSE X C-57 C-61 D-09 Other - <br />CITY/ZIP Lathrop, CA <br />SIZE 17 , 3 41' LAND USE APPLICATION #_ <br />PHONE <br />CITY/STATE/ZIP Modesto, CA 95356 <br />PHONE 559-348-2200 <br />CITY/STATE/ZIP Clovis, CA 93612 <br />PHONE <br />CITY/STATE/ZIP <br />499908 10/31 /2022 <br />NUMBER EXPIRATK)N DATE. — <br />DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) Cl Arsenic (43a3) <br />INTENDED USE Domestic/Pdvate Irrigation/Agricultural Industrial - Water Quality Monitonng Soli Sampling/Characterization <br />Public Water System – If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK 1 New Well Replacement Well Well Alteration/Modification Other <br />:Monitonng Well(s) # of wells Soil Boring # of borings s) )( Geotechnical <br />C Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />New Pump Pump Replacement Pump Repair Raise Well Casing <br />8 # of borings <br />(10-50 Feet) <br />WELL CONSTRUCTION <br />Drilling Method Mud Rotary Air Rotary Auger I Cable Tool Push Point X Other <br />Hollow Stem Auger <br />Proposed Well Depths - J ft Excavation in diameter Open Bottom Gravel Pack/Gravei Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched f. Steel Plastic Stainless Steel Other <br />Grout Seal DepthiJ -� ft )( Neat Cement (941b bag/5 JO gal water) Sand Cement sacApAYWNTer <br />Bentonite (20% solids) :: Other RECEIVED <br />Grout Placement Method Pumped - Free Fall Other Retardant / Accelerator (name) _ __� <br />— kA A i _1I]LL <br />PEDESTAL Installed By Driller Pump Contractor <br />Concrete Pedestal Dimensions: Width _ <br />in Christy Box t Stove Pipe <br />Other_ <br />ft Length <br />ft Thick S N JOAQUIN G-1 <br />ENVIRON, <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 />MINIMUM 24 HOUR ADV'ANCF. NOTICE REQUIRED FOR INS11X HUNS - PLEASE CALL (209) 953-7697 <br />DEPARTMENT USE ONLY <br />Application Accepted By e�__ 41 " Z– _ Date <br />Grout Inspection By <br />Date <br />Pump Inspection By _ M____ Date Date <br />�i <br />Soil Boring Inspection By - �� ` � -- <br />COMMENTS <br />AreaS' �` 111I_ ' Employee ID#� <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth <br />ft <br />T <br />PE SC Received Check#r Amount Date – Permit/Invoice <br />�l Codes Into B Cash Remitted eryice Request # <br />wil- <br />)�o Is -� �.v.�S/ <br /># Well ID# , <br />EHD043-06 10/25'021 Pac. I of 2 �'ti r NuRp VC—L <br />