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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 />NON-REFUNDABLE PERMIT GALL ZU9 953-7697 FOR INSPECTIONS tAPIKtb 1 YEAR FROM DATE ISSUED <br />ADDRESS (6 _%W'1T Mt. Diablo Avenue and C Street C IIP /Z Tracy, CA <br />CROSS STREET <br />OWNER NAME Byrum Investments, LLC <br />OWNER ADDRESS 6 Castledown Road <br />CONTRACTOR Krazan & Associates, Inc <br />TY <br />APN d35'10077 PARCEL SIZE 3.38 ac LAND USE APPLICATION # <br />PHONE 925-980-0334 <br />CITY/STATE/ZIP Pleasanton, CA 84566 <br />PHONE 559-348-2200 <br />CONTRACTOR ADDRESS 215 W. Dakota Avenue CITYISTATE/ZIP Clovis, CA 93612 <br />SUBCONTRACTOR Krazan & Assoviates, Inc <br />SUBCONTRACTOR ADDRESS 215 W. Dakota Avenue <br />LICENSE X C-57 I C-61 I i D-09 I 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 />NTENDED USE Domestic/Private I i 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 <br />New Well C` Replacement Well I- Well Alteration/Modification Other <br />Amount Date Permit/ Invoice # Well ID# <br />Remittedvice Re uest # <br />937:2 <br />Monitoring Well(s) # of wells Soil Boring # of borings X <br />Boring(s) Geotechnical <br />8 # of borings <br />P <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />' <br />(15-50 Feet) <br />New Pump fa. Pump Replacement Pum Repair Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method <br />'; - Mud Rotary Air Rotary Ci Auger ❑ Cable Tool Push Point Other <br />Proposed Well <br />Depth ft Excavation in diameter ; Open Bottom Gravel Pack/Gravel Size s i di r#t� <br />v�N <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />✓Qq ' <br />QU/N <br />Well Casing <br />Diameter in Thickness/Gauge/ASTM Sched Steel :' Plastic ' Stainless Steel <br />G d{rLer6/vO <br />Grout Seal <br />Depth ft X Neat Cement (94 Ib bag/5-10 gal water) Sand Cement <br />sac k t <br />Bentonite (20% solids) Other <br />/ll <br />Grout Placement Method H Pumped [: Free Fall I.! Other Retardant! Accelerator (name) <br />2EDESTAL Installed By F Driller r' Pump Contractor Other <br />Concrete Pedestal I:::Dimensions: Width ft Length ft Thick <br />n Christy Box C Stove Pipe <br />PUMP Submersible[: 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 />NII:NIRIIN1 24 IfOt7R AI)% ANC E NO I ICE, 10"Qt IRED FOIL INSPECTIONS - 111 F ASI-: C'AIJ, (2119) 953-7697 <br />DEPARTMENT 4SUE ONLY <br />.I7 .i;z Area Tf�'ac EmployeeID# As <br />' Application Accepted By _ Date � <br />Grout Inspection By Date ..I SPECIAL Well Permit <br />Pump inspection By of Date 7 WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />T <br />1 <br />rn <br />D <br />0 <br />0 <br />M <br />rn <br />CA <br />CA <br />PE <br />Codes <br />SC Received Chec <br />Info By sh <br />Amount Date Permit/ Invoice # Well ID# <br />Remittedvice Re uest # <br />937:2 <br />Std <br />S a <br />G <br />'EHD013-06 03;07!30211 Page I of 2 Well Pump Permit <br />`t2 <br />V r `� <br />