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I. WELLIPUMP PERMIT <br />SAN JOAQUiN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 'i YEAR FROM DATE ISSUED <br />Joe ADDRESS 12999 Blossom Court a ^ CITY/ZIP Loo'ckeford, CA <br />CROSS STREET JtejtF APN O 1 J `l 9 PARCEL SIZE `' LAND USE APPLICATION # <br />OWNER NAME O'Reilly Automotive - � t `� �'/�. Pc nth .)i 41 LL ( E TA L PHONE <br />233 S. Patterson Avenue /T:J Springfield, MO 65802 <br />OWNER ADDRESS CITY,STATEIZIP I t-14vf , + <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 & Assoyiates, Inc PHONE 559-348-2200 <br />SUBCONTRACTOR ADDRESS 215 W. Dakota Avenue CITY/STATE/ZIP Clovis, CA 93612 <br />LICENSE X C-57 I i C-61 l l D-09 ❑ Other 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 0 Irrigation/Agricultural ::: Industrial Water Quality Monitoring 1 Soil Sampling/Characterization <br />E Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK C New Well Cl Replacement Well 0 Well Alteration/Modification Other <br />C:; Monitoring Well(s) # of wells I::) Soil Boring(s) n of borings X Geotechnical 6 a of borings <br />0 Out -Of -Service Well 0 Out -Of -Service Well Renewal Cross -Connection Repair 10-50 Feet <br />New Pump I:] Pump Replacement 0 Pump Repair Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method Mud Rotary 0 Air Rotary ' P Auger G' Cable Tool Push Point ] Other <br />Proposed Well Depth 1,3 -50 ft Excavation in diameter E Open Bottom C Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched 7 Steel D. Plastic . Stainless Steel 1 Other <br />Grout Seal Depth ij S-0 ft X Neat Cement (94 lb bag/5-10 gal water) ;' Sand Cement _sack 7NH�Tqjer <br />Bentonite (20% solids) [1 Other RECEIVE <br />Grout Placement Method 1: Pumped I I Free Fall [1 Other C: Retardant ; .Accelerator (name) <br />PEDESTAL Installed By ❑ Driller 0 Pump Contractor (511her <br />Concrete Pedestal DDimensions: Width ft Length ft Thick _ 111L, 1 tiTv <br />in Christy BOX C Stove.Pipe ENVIRONMENTP.I_ <br />PUMP Submersiblel 1 Turbine I; 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 />NIININItNI 24 HOUR ADVANCE NOTICE REQUIRED I OR INSPECTIONS - PI EASE CAI.1" (2119) 9+3-7697 <br />�srx <br />DEPARTMENT USE ONLY <br />Application Accepted By � � `— Date Area r_ ��� Employee ID# <br />F rl <br />Grout Inspection By Date. _l SPECIAL Well Permit <br />Pump InspectionBy Date WAIVER Received <br />Soil BoringInspection By Date Constructed Well Depth ft <br />COMMENTS_/ft?1Vt1P 42Aat7f�11 t Of C"tJL;?(,VJrJF'►' is PkynuUl <br />to <br />m <br />m <br />D <br />0 <br />0 <br />z <br />M <br />rn <br />q!25F <br />PE <br />Codes <br />SC Received <br />Info By <br />Checl l <br />Cash <br />Amount Permit/ <br />Remitted Date Service Request # Invoice # Well ID# <br />437J <br />150 <br />16� <br />EiD043-06 04,072022 Pate 1 of 2 W,11 P1 V Permit <br />