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NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS Brovelli Woods Lane CITY/ZIP Acampo, CA <br /> <br />s ey L ApN 003-100-330-00 <br />OWNER NAME Blankenship - d VOCI <br />PARCEL SIZE 90 LAND USE APPLICATION # <br />PHONE <br />(611/FL 9S-4)3 <br />CROSS STREET <br />OWNER ADDRESS R0 1---fes"-t Like. kci. CITY/STATE/ZIP <br /> <br />CONTRACTOR <br /> Krazan & Associates, Inc <br />PHONE 559-348-2200 <br />215W. Dakota Avenue CONTRACTOR ADDRESS <br />SUBCONTRACTOR Krazan & Assoviates, Inc <br />CITY/STATE/ZIP Clovis, CA 93612 <br />PHONE 559-348-2200 <br />215 W. Dakota Avenue SUBCONTRACTOR ADDRESS <br />Clovis, CA 93612 cm/swot/zip <br />LICENSE X C-57 L, C-61 11 D-09 1.1 Other NUMBER 499908 EXPIRATION DATE <br /> 10.31.2022 <br /> <br />Application Accepted By <br />Grout Inspection By <br /> <br />Pump Inspection By <br />Date "7" Of— <br />Date <br />tij <br />DEPARTMENT USE ONLY <br />Date <br />1 WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE 0 Domestic/Private n Irrigation/Agricultural E Industrial T Water Quality Monitoring 1:J Soil Sampling/Characterization <br />Public Water System <br /> <br />If different from Owner Water System Name Contact Name or Phone Number <br />TYPE OF WORK E New Well E Replacement Well El Well Alteration/Modification : Other <br />Monitoring Well(s) # of wells H Soil Boring(s) # of borings X Geotechnical 3 S ot borings <br />ri Out-Of-Service Well 0 Out-Of-Service Well Renewal :,-, Cross-Connection Repair 10-50 Feet <br />0 New Pump D Pump Replacement Ili Pump Repair E Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method 2 Mud Rotary o Air Rotary Li Auger E Cable Tool 1 Push Point 2 Other <br />Proposed Well Depth /3 -.5O ft Excavation in diameter 0 Open Bottom 2 Gravel Pack/Gravel Size <br />1E Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched E Steel 7 Plastic 'T Stainless Steel n Other <br />Grout Seal Depth jD --:.;\) ft X Neat Cement (94 lb bag/5-10 gal water) : Sand Cement <br />, Bentonite (20% solids) H Other RECEIVED <br />Grout Placement Method H Pumped I Free Fall H Other Retardant / Accelerator (name) <br />PEDESTAL Installed By IT Driller El Pump Contractor Other <br />Concrete Pedestal H Dimensions: Width ft Length <br />Li Christy Box 11 Stove Pipe <br />in diameter <br />PA V4181Erpft7 gal water <br />UN 21 ali22-- <br />ft Thick. SAN JOAQUIN COUNT`g <br />ENVIRONMENTAL HEALTH DCPARTmEnir <br />PUMP • Submersiblet:11 Turbine 0 Other HP Pump Set ft Standing Water Level ft <br />Plot Plan Requirements: Attach a plot ptan 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 />poteptial 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 />SIINIMI:M 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (2119) 953-7697 <br />Soil Boring 14pectioni By Date <br />COMMENTS tierv +0 bc c1fre_p_Lc_the:11_3_Q_et z3r <br />Area LI / (14 : Employee ID# <br />Ii SPECIAL Well Permit <br />II WAIVER Received <br />Constructed Well Depth <br />vs;CJ IFtr s <br />enca,,--p-tetpd <br />ft :SSUCK:111 311S PE <br />Codes <br />SC <br />Info <br />Received <br />By <br />Check#/ <br />C_ash <br />Amount <br />Remitted Date Permit/ <br />Service Request # Invoice # Well ID# <br />937a 15-D 3.5 1.10,5) 474D 10 :1=-1 /71-- OP0`) 4124iz <br />EHD443-06 04/07/2022 Well Pump Parma Page I of 2