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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 (LUVI U04 -✓by✓ FOR INSPECTIONS tAt'IKtJ l TEAR FROM UATE ISSUED <br />JOB ADDRESS ho Awlerice" sitea CITY/ZIP Stockton, CA gS'aaa <br />1 <br />CROSS STREET A c, ,4c' l A APN X39 a l o o PARCEL SIZE 03 LAND USE APPLICATION # <br />OWNER NAME California State University Stanislaus/Sfafe 6'c CC411&&"Ie, PHONE <br />OWNER ADDRESS One University Circle /d4ig F; fsi Ave W A156 Turlock,, CA�Sticfgr► w► o <br />/ 4 CITvISTATE/ZIPS <br />CONTRACTOR Krazan & Associates, Inc PHONE 559-348-2200 <br />CONTRACTOR ADDRESS 215 W. Dakota Avenue CITY/STATE/ZIP Clovis, CA 93612 <br />SUBCONTRACTOR Krazan & Assoviates, Inc <br />SUBCONTRACTOR ADDRESS 215 W. Dakota Avenue <br />LICENSE X C-57 I C-61 11 D-09 I Other <br />PHONE 559-348-2200 <br />CITY/STATE/ZIP Clovis, CA 93612 <br />NUMBER 499908 EXPIRATION DATE 10.31.2022 <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE Domestic/Private I7 Irrigation/Agricultural Industrial Water Quality Monitoring I:] 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 <br />I:J Well Alteration/Modification .- Other <br />Monitoring Well(s) # of wells Ii Soil Boring(s) <br />- Out -Of -Service Well I, Out -Of -Service Well Renewa <br />' New Pump I' Pump Replacement ❑ Pump Repair <br /># of borings X Geotechnical 2 # of borings <br />I Cross -Connection Repair (25 to 50 Feet) <br />Raise Well Casino <br />WELL CONSTRUCTION 7 j <br />Drilling Method Mud Rotary I? Air Rotary 1 1 Auger I; Cable Tool Push Point Other RE <br />Proposed Well Depth oZ S' -gyp ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size �y in diame 6r <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel C Otl* <br />Grout Seal Depth of S-S'b ft X Neat Cement (94 lb bag/5-10 gal water) i, Sand Cement S� ) water <br />[ <br />Bentonite (20% solids) i Other <br />Fq� t�RCNnN CO <br />Grout Placement Method I' Pumped [] Free Fall Other Retardant / Accelerator (name) pq p„Tq <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 I 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 />MINIRIt !t 24 1101 R ADl'A SCE NO1 ICE: IiFQt IRED I'OR INSPLCI'IONS - PLEASE CALL (2119) 953-7697 <br />DEPARTMENT USE ONLY <br />Application Accepted By J Date <br />Grout Inspection By Date <br />Pump Inspection By Date <br />Soil Boring Inspection By Date <br />COMMENTS <br />Area �q / Employee ID# /►r <br />I SPECIAL Well Permit <br />I WAIVER Received <br />Constructed Well Depth <br />ft <br />✓T <br />PE SC Received (Ct2sW <br />Codes Info B Cash <br />Amount Date Permit/ Invoice # Well ID# <br />Remitted Service Request # <br />37a <br />i 608 ' <br />EUD043-06 04.07r:022 Page 1 or' Well Papp Permit <br />