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1 WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)4683420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> 2716 E. Miner Avenue Stockton, CA <br /> JOB ADDRESS CrrY/ZIP <br /> Lr_ D <br /> CROSS STREET � JP ApN 143-44-002 PARCEL SIZE I I1 LAND USE APPLICATION# O <br /> OWNER NAME <br /> Grimaud Farms H fl C C�„b/fc 1 L L L PHONE w <br /> OWNER ADDRESS 2716 E. Miner Avenue CITY/STATE/ZIP Stockton , CA 95205 <br /> CONTRACTOR Krazan $Associates, Inc PHONE 559-348-2200 <br /> CONTRACTOR ADDRESS 215 W. Dakota Avenue CITY/STATEIZIP Clovis, CA 93612 <br /> SUBCONTRACTOR Krazan &Assoviates, Inc PHONE 559-348-2200 <br /> SUBCONTRACTOR ADDRESS 215 W. Dakota Avenue CITY/STATE/ZIP Clovis, CA 93612 <br /> LICENSE X C-57 C-61 �i D-09 L1 Other NUMBER 499908 EXPIRATION DATE 10.31.2022 <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391)❑ Dibromochloropropane(4392)11 Arsenic(4393) <br /> INTENDED USE U Domestic/Private U Irrigation/Agricultural U Industrial ❑Water Quality Monitoring 'Soil Sam pling/Characterization <br /> Public Water System <br /> II different from Owner Water System Name Contact Name or Phone Number <br /> TYPE OF WORK i I New Well i I Replacement Well C Well Alteration/Modification ❑ Other <br /> 'l Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings X Geotechnical 3 #of borings <br /> 1 Out-Of-Service Well I i Out-Of-Service Well Renewal 7 Cross-Connection Repair (20-50 Feet) <br /> New Pump U Pump Replacement U Pump Repair i Raise Well Casing <br /> WELL CONSTRUCTION p <br /> _ <br /> Drilling Method Mud Rotary U Air Rotary Cl Auger U Cable Tool -i Push Point t Other <br /> Proposed Well Depth F. �"�`� ft Excavation in diameter II Open Bottom I1 Gravel Pack/Gravel Size �r <br /> L Conductor Casing in diameter / Conductor Casing Depth ft R <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched U Steel U Plastic ❑ Stainless Steel Other <br /> Grout Seal Depth d O-S d ft X Neat Cement(94 Ib bag/5-10 gal water) i] Sand Cement � plix/7 g ate <br /> Bentonite(20%solids) U Other ,AI R0 CO/]A]A­ <br /> ,Grout Placement Method U Pumped I 1 Free Fall U Other U Retardant/Accelerator(name) FP T <br /> PEDESTAL Installed By U Driller ❑ Pump Contractor I l Other <br /> Concrete Pedestal F1Dimensions:Width ft Length It Thick <br /> �in ii Christy Box I-, Stove Pipe <br /> PUMP Ll 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 YOUR ADVANCE NOTICE.REQUIRED FOR INSPECTIONS-PLEASE CALL(209)951_7097 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By �� Date y / » Area 1/5 bG 001 Employee ID# /7S <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By gate I 1 WAIVER Received <br /> Soil Boring Inspection ByDate�t ^ �7 <br /> �-. ` Z Constructed Well Depth H <br /> COMMENTS I Ito 14? r v_ Q <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info Cash Remitted Service Request# <br /> 3-7,2 ls-0 Vi 7 O 21 tU <br /> FI ID043-06 04/07/2022 Page I of 2 Well/Pump Pcmn <br />