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1 WELL/PUMP PERMIT <br />M SAN .JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT GALL LUy VO -5-1 btl I FUR IN5PtG I IUNb CArIRCJ 1 r rAK rKUnn vAI r- waucU <br />JOB ADDRESS 164 W. Grant Line Road CITY/ZIP Tracy, CA <br />CROSS STREET 001 APN 233-210-230 PARCEL SIZE 173 LAND USE APPLICATION # <br />OWNER NAME Jatinder Randhawa PHONE 703-501-7136 <br />OWNER ADDRESS 1136 S. Jacobs Drive CITY/STATE/ZIPMOutaln House, CA 95391 <br />CONTRACTOR Krazan & Associates, Inc. <br />CONTRACTOR ADDRESS 215 W. Dakota Avenue <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE X C-57 C-61 :- D-09 Other <br />559-348-2200 <br />PHONE <br />CITY/STATE(ZIP Clovis, CA 93612 <br />CITY/STATE/ZIP <br />NUMBER 499908 <br />PHONE <br />EXPIRATION DATE 10/31/2022 <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 <br />TYPE OF WORK <br />New Well _ Replacement Well = Well Alteration/Modification -- Other <br />Permit/ <br />Da �ervice Request # Invoice # Well ID# <br />= Monitoring Well(s) # of wells -Soil Boring # of borings <br />Boring(s) X Geotechnical <br /># of borings <br />Out -Of -Service Well Out -Of -Service Well Renewal _ Cross -Connection Repair <br />(10-50 Feet) <br />New Pump _ Pump Replacement - Pump Repair - Raise Well Casing <br />0A %,. - <br />WELL CONSTRUCTION <br />R , I •I El vT <br />eCE%14 <br />Drilling Method <br />= Mud Rotary Air Rotary -- Auger _ Cable Tool Push Point - Other <br />e� <br />Proposed Well <br />Depth lz)-j J ft Excavation in diameter L Open Bottom - Gravel Pack/Gravel Size_ in diam <br />- Conductor Casing in diameter / Conductor Casing Depth ft <br />n 022 <br />Well Casing <br />Seal <br />Diameter in ThicknesslGauge/ASTM Sched - Steel - Plastic - Stainless Steel ,4W�}ter <br />S <br />Depth iJ' -s Z) ft Neat Cement (94 lb bagl5-10 gal water) - Sand Cement PAP,��( f#j V1 water <br />Grout <br />X <br />�ALTNP <br />Bentonite (20% solids) - Other <br />R7.AlL_ <br />7. <br />Grout Placement Method -_ Pumped -_Free Fall - Other Retardant / Accelerator (name) <br />Al <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 />1IENIA11 !'I 24 IiOt RAO\ AN('E NOTICE RE Q11 [RED t,(}R INSPht'TIONS - I't LASE (`ALI, (209) 953-7697 <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />L <br />DEPARTMENT USE ONLY <br />Date_ <br />Date <br />Date <br />_ Date S 2� <br />Area �(�1L Employee ID# 4 <br />L7 SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth <br />or t F e,toUY►64*s <br />It <br />T <br />M <br />M <br />D <br />0 <br />z <br />M <br />N <br />fn <br />PE SC Received Chec <br />Codes Info By- as <br />37a <br />Amount <br />Remitted <br />Permit/ <br />Da �ervice Request # Invoice # Well ID# <br />EnD043-06 10,2512021 Page 1 of WeilPimp Pena <br />