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t <br />/ 0 <br />WELL/PUMP 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 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 147 Warren Avenue CITY/ZIPLathrop, California 95330 <br />CROSS STREET Reverend Maurice Cotton Dr. APN 196-050-71 PARCELSIZEe11 <br />LAND USE APPLICATION# <br />OWNER NAME David randt / ' `' PHONE <br />OWNER ADDRESS 147 Warren Avenue / / qs �k �W A -y e— CITY/STATE/ZIP Lathrop, California 95330 <br />CONTRACTOR Krazan & Associates, illinc. PHONE 559.348.2200 <br />CONTRACTOR ADDRESS 215 W. Dakota Avenue CITY/STATE/ZIP Clovis, California 93612 <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br />LICENSE J C-57 C-61 D-09 Other NUMBER 499908 EXPIRATION DATE 10/31/2018 <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br />WENDED USE Domestic/Private Irrigation/Agricultural Industrial . Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System <br />If different from Owner: water bYSt6M Narne on a arae or One um er <br />TYPE OF WORK New Well Replacement Well . Well Alteration/Modification Other <br />MonitoringWells # of wells Soil Boring(s) s # of borings 2 # of borings <br />O gO f Geotechnical <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair 10-50 Feet) <br />Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br />Proposed Well Depth ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter412 in rThickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br />Grout Seal Depth/0 VU It N% Neat Cement (941b bag15-10 gal water) Sand Cement sack mix/7 gal water <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 in Christy Box Stove Pipe <br />PUMP Submersible Turbine Other HP Pump Set It Standing Water Level ft <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />—1111111&f 2 HH A JV9 E NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 963-7697 <br />jj Managing Engineer 3/13/2018 <br />SIGNED �ti TITLE DATE <br />RE <br />ENVIRON <br />u E, <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection y <br />COMMENTS <br />PA <br />MENT U E N/y}Y <br />Date �G <br />Date <br />Date <br />Date _ <br />rn <br />a <br />O <br />1�W <br />AreaEmployee I� <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth ft <br />PE SC Received <br />Codes Info B <br />CQhe0dK <br />ash <br />Amount Date <br />Remitted <br />Permit/ Invoice # <br />Service Re uest# <br />Well ID# <br />t4)3-2. <br />EHD 4308 <br />4/30/12 <br />WELL 1PUMP PERMIT <br />