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t 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 445 North Walnut Avenue CITY/ZIP Manteca, California <br />CROSS STREET Alameda Street APN�O �O PARCEL SIZE LAND USE APPLICATION # <br />OWNER NAME Palm Jr, LLC PHONE 209-422-3011 <br />OWNER ADDRESS 1113 Palm Avenue CITY/STATE/ZIP Modesto, CA 95350 <br />CONTRACTOR Krazan & Associates, Inc. PHONE 559.348.2200 <br />CONTRACTOR ADDRESS 215 W. Dakota Avenue CITY/STATE/ZIP Clovis, CA 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 />NTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System <br />Ir different from Owner: Water bystern Nam Contact Name or Phone Number <br />TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br />MonitoringWells # of wells Soil Boring(s) s # of borings 4 # of borings <br />O 9O Geotechnical <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair (10-50Feet) <br />New Pump Pump Replacement Pump Repair Raise Well Casino <br />Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br />Proposed Well Depth 0 l ro ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter 41/' in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br />Grout Seal Depth j) L11�fO ft V Neal Cement (94 lb bag/5-10 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 It Thick in Christy Box Stove Pipe <br />PUMP Submersible Turbine Other HP Pump Set ft 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 />ANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />2 /- TITLE Managing Engineer — DATE 05/15/2018 <br />_0 <br />ig <br />D <br />0 <br />m <br />N <br />PA TMEN�4S <br />E N Y <br />Application Accepted By ' Date Area;0&imployee ID# <br />Grout Inspection By Date SPECIAL Well Permit <br />Pump Inspection By Date / WAIVER Received <br />Soil Boring Inspection By A& &e' Date (0 L� Constructed Well Depth ft <br />COMMENTS <br />PE Sc <br />Codes Innffo� <br />Received eck# <br />B <br />Amount Date <br />Remitted <br />Permit/ Invoice # Well ID# <br />Service Request # <br />`5D <br />33--b]� <br />-JOI l <br />I oo-5 Z� V <br />EHC 43-05 WELL /PUMP PERMIT <br />4/30/12 <br />