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1 WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN-KEFUNDABLE PERMIT t;ALL ZUy ybS-1bU1 FOR INSPECTIONS t_AI'IKt5 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 26820 South Hansen Road CITY/ZlP Tracy, CA <br />CROSS STREET SCh <br />OWNER NAME Economy Pallets 7>( <br />OWNERADDRESS 2588S. Miami Avenue <br />CONTRACTOR Krazan & Associates, Inc <br />CONTRACTOR ADDRESS 215 W. Dakota Avenue <br />SUBCONTRACTOR Krazan & Assoviates, Inc <br />APN a �� a 3 o a 1 PARCEL SIZE C1. 9S7' <br />LAND USE APPLICATION # <br />PHONE <br />CITY/STATE/ZIP Fresno, CA 93727 <br />SUBCONTRACTOR ADDRESS 215 W. Dakota Avenue <br />LICENSE X C-57 1 C-61 D D-09 f j Other <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 10.31.2022 <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE Domestic/Private I:) Irrigation/Agricultural i:::i 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 ❑ Well Alteration/Modification Other <br /># of borings a of borings <br />Monitoring Well(s) # of wells I:7 Soil Boring(s) X Geotechnical //�� <br />Out -Of -Service Well Ei Out -Of -Service Well Renewal Cross -Connection Repair (15 - 50 Ft) A Y <br />New Pump CJ Pump Replacement L) Pump Repair Raise Well Casing Alipf <br />Drilling Method _ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point Other <br />Proposed Well Depth 1S`Sa ft Excavation in diameter Open Bottom _; Gravel Pack/Gravel Size in tl a et�r <br />i <br />G Conductor Casing in diameter 1 Conductor Casing Depth ft N JOq <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched Steel Plastic _; Stainless Steel I7 Oth EN -I QVIN t <br />Grout Seal Depth S-,Sa ft X Neat Cement (941b bag/5-10 gal water) Sand Cement sack mf <br />Bentonite (20% solids) I:' Other <br />Grout Placement Method ID Pumped U. Free Fall L) Other Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑Pump Contractor _. Other <br />Concrete Pedestal ❑Dimensions: Width ft Length ft Thick <br />n Christy Box ❑ Stove Pipe <br />PUMP I SubmersibleD Turbine Ul 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 />NIENIN111=N1 24 HOCR ,ADVANCE NO] WE: I(E:Qt'1RED IQR INSPECTIONS - PLEASE ('ALA. (209) 953-7697 <br />DEPARTMENT USE ONLY t3�3 <br />Application Accepted By Date �� L Date S a3 as Area S % -/ Employee ID# A5 <br />Grout Inspection By Date D SPECIAL Well Permit <br />Pump Inspection By Date 7 WAIVER Received <br />Soil Boring Inspection.ByDate Constructed Well Depth ft <br />COMMENTS -Tiemie f_ be' UseCl If <br />OteevOr the4ki raU)7d Jot <br />PE SC Received Amount DatePermit/ Invoice # Well ID# <br />Codes Info B Cash Remitted ervice Request # <br />379 sa ZZL GO �' 2 <br />EHDt143-06 04%0712022 Page I of', Well, Plump Permit <br />L <br />