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I WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN-KEFUNDABLE PERMIT GALL (ZU9) 953-7697 FOR INSPECTIONS EXPIKE5 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 232 W. Pearl Avenue CITY/ZIP Stockton, CA �Gi <br />CROSS STREET f ✓` 1�& O0� APN ����J�/ J PARCEL SIZE O_�AND USE APPLICATION <br />OWNER NAME Jeff Hagler PHONE 209.298.9002 <br />OWNER ADDRESS 3045 Del Rio Avenue CITY/STATE/ZIP Stockton, CA 95204 <br />CONTRACTOR Krazan & Associates, Inc <br />CONTRACTOR ADDRESS 215 W. Dakota Avenue <br />SUBCONTRACTOR Krazan & Assoviates, Inc <br />SUBCONTRACTOR ADDRESS 215 W. Dakota Avenue <br />LICENSE X C-57 ❑ C-61 i D-09 ❑ 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 E 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 ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br /># of borings 3 # of b0P <br />❑ Monitoring Well(s) # of wells ❑Soil Boring(s) � Geotechnical i/''�� <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair (10-50 Feeik 4ljE <br />❑ New Pum ❑ Pum Replacement ❑ Pum Repair ❑ Raise Well CasingC <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other AU <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size SA nSIn di m <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft /y� EIV / AQUIN <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched 11Steel F1Plastic ElStainless Steel 11O 1- RONM COU <br />Grout Seal Depth ft X Neat Cement (94 /b bag/5-10 gal water) ❑ Sand Cement sack mix <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ 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 ❑ SubmersibleC 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 />NIININIITNI 24 IIOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />DEPARTMENT USE ONLY Z16�� �A <br />Application Accepted By Date / Z� �Za2� Area mployee ID# <br />Grout Inspection By Date ❑ SPECIAL Well Permit <br />Pump Inspection By Date ❑ WAIVER Received <br />Soil Boring Inspection By � � L" Date -f — 2OA-d— Constructed Well Depth <br />COMMENTS <br />ft <br />T <br />-4 <br />M <br />v <br />0 <br />M <br />M <br />CA <br />N <br />(% <br />1J <br />PE Sc Received <br />Codes Info BY, <br />Amount Date Permit/ Invoice # Well ID# <br />Cash Remitted Service Request # <br />-7E6 S <br />EHDO43-06 04/07/2022 Page I or 2 Well / Pump Permit <br />