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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 />NUN-KEFUNDABLE PERMIT CALL (209) 953-7697 FOR !NSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JoB ADDRESS G (i'�3 Trinity Parkway <br />/land Scott Creek Drive _ CITYIZIP Stockton, CA <br />CROSS STREET r i ► "' ' Al.066" 5� PARCEL SIZE )7141 <br />-_.LAND USE APPLICATION # <br />OWNER NAME I O Burger mS ��y ( �,-� e U� ! /1e PHONE <br />OWNER ADDRESS <br />13502 Hamburger Lane Slop 0 S $ CITYISTATE1ZIp Baldwin Park, CA 91706 - Een fonv. <br />-. �G'rI+ <br />CONTRACTOR Krazan & Associates, Inc. PHONE 559-348-2200 <br />CONTRACTOR ADDRESS 215 W. Dakota Avenue _ CITYISTATEIZIP Clovis, CA 93612 <br />ADDRESS <br />LICENSE X C-57 ❑ C-61 ❑ D-09 J Other <br />PHONE <br />CITYISTATE/ZiP <br />499908 10/31/2022 <br />NUMBER EXPIRATION DATE <br />DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) ❑ D!bromochloropropane (4392) ❑ Arsenic (4393) <br />INTENDED USE ❑ Domestic/Private C IrrigationiAgricultural " Industrial ❑ Water Quality Monitoring J Soil Samplfng/Characterization <br />❑ Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK C New Welt ❑ Replacement Well ,D Well Alteration/Modification D Other <br />Monitoring Well(s) # of wells D Soil Boring(s) # of borings Geotechnical 6 # of borings <br />Out -Of -Service Well ❑ Out -Of -Service Well Renewal D Cross -Connection Repair (10-50 Feet) <br />C New Pump D Pump Replacement D Pump Repair "? Raise Well Casino <br />Drilling Method 0 Mud Rotary ❑ Air Rotary ❑ Auger f i Cable Toot ❑ Push Point 4C Other Hollow Stem Auger <br />Proposed Well Depth 10 `.5 D ft Excavation _ in diameter ❑ Open Bottom J Gravel Pack/Grave! Size in diameter <br />❑ Conductor Casing in diameter I Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched D Steel C Plastic E. Stainless Steel -- Other <br />Grout Seal Depth i0- SQ _ft IX Neat Cement (94 Ib bag/5.10 gal water) n Sand Cement sack 4NEl <br />❑ Bentonite (20% solids) ❑ Other RE EIV <br />Grout Placement Method D Pumped C Free Fall ❑ Other D Retardant / Accelerator (name) <br />PEDESTAL Installed By L Driller Pump Contractor <br />❑ Concrete Pedestal ❑Dimensions: Width _ <br />in ❑ Christy Box ❑ Stove PiDO <br />❑ Other_ <br />ft Length <br />ft Thick <br />PUMP D Submersible❑ Turbine Other HP Pump Set It Standing Water Level — It <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 AD'y ANCE "yi' TICE: REQ1'IRED FOR INSPECTIONS -PLEASE C'ALT, (209) 453-7647 <br />DEPARTMENT USE ONLY <br />Application Accepted By Z_ Date _'1d y as <br />Grout Inspection By Date <br />Pump Inspection By <br />Soil Boring Inspection By <br />,MMENTS :n eW! I e <br />30 <br />re e4 - <br />Dale <br />Date <br />Area 3&Zk'1 "i7Employee ID# <br />0 SPECIAL Well Permit <br />D WAIVER Received <br />Depth <br />ft <br />1A 7/,� <br />PE Sc Received Check#/ Amount T <br />Codes Info B Cash Remitted <br />ate Permit' Invoice # Well ID# <br />i e Request # <br />3�a so a <br />EKDO43-06 10252021 Page 1 of 2 Well ! Nn'P Permit <br />