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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 (:ALL (ZU8) 9bJ-/b9/ FOR INSPECTIONS t_XPIKLS 'I YEAR FROM UATE ISSUED <br />JOB ADDRESS 15820 S. Harland Road �j% CCITY/ZIPLaVthrop, CA <br />CROSS STREET namsen P' C,APN i �/ Cl d 7 0 015 PARCEL SIZE ` S `/ LAND USE APPLICATION # <br />OWNER NAME Salip LLC V„ 1 r✓1 .3 -To S +Pyoar l Fawl l )y P7 F PHONE <br />OWNER ADDRESS <br />CONTRACTOR <br />Krazan & Associates, Inc <br />CONTRACTOR ADDRESS 215 W. Dakota Avenue <br />SUBCONTRACTOR Krazan & Associates, Inc. <br />SUBCONTRACTOR ADDRESS 215 W. Dakota Avenue <br />LICENSE X C-57 C-61 D-09 Other <br />CITY/STATE/ZIP <br />PHONE 559-348-2200 <br />CITY/STATE/ZIP Clovis, CA 93612 <br />PHONE 559-348-2200 <br />CITY/STATE/ZIP Clovis, CA 93612 <br />NUMBER 499908 EXPIRATION DATE 10/31/2021 <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) 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 A <br />TYPE OF WORK New Well Replacement Well <br />Monitoring Wells) # of wells <br />Out -Of -Service Well <br />New Pump Pump Replacement <br />Well Alteration/Modification <br />Soil Boring(s) <br />Out -Of -Service Well Renewal <br />Other <br /># of borings X Geotechnical 5 # of borings <br />Cross -Connection Repair (10-50 Feet) F <br />Raise Well Casino <br />W <br />m <br />D <br />0 <br />0 <br />A <br />W <br />c �/VT <br />., FO <br />WELL CONSTRUCTION JgN✓O (% <br />Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other NcF q <br />Proposed Well Depth 10-S"O ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size Tly1 <br />Conductor Casing in diameter / Conductor Casing Depth ft qR <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other T 0Grout Seal Depth )0--5-45 ft X Neat Cement (94 Ib bag/5-10 gal water) Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) Other <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 <br />in Christy Box Stove Pipe <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 ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />DEPARTMENT USE ONLY <br />Application Accepted By �/�� �— DateVI—It <br />4 o�oZ <br />Grout Inspection By �ttnotea. �:� A.`7 Date 2 <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS -rre rn 4 's <br />Q. <br />Date <br />Date <br />30 <br />Area 3 Lath rO Employee ID# <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth <br />PE SC Received Check#/ Y Amount Date Permit] Invoice # Well ID# <br />Codes Info B Remitted Service Request # <br />ft <br />EHDO43-06 10/25/2021 Page I of 2 Well / Pump Permit <br />