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r <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1866 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 /> 2900 Fremont Street Stockton.CA y <br /> JOB ADDRESS CITY/ ryi <br /> .5'a sl• s� n <br /> CROSS STREET APN PdRCEL SIZE LAND USE APPLICATION# a <br /> A <br /> ATC Design Group760-7388000 <br /> OWNER NAME PHONE e! <br /> OWNERADDRESS 1282 Pacific Oaks Place Suite C I(A& & j(/&4^�CITY/ST E/LP Escondido,CA 92029 <br /> CONTRACTOR Krazan&Associates,Inc. •���' PHONE 559.3482200 <br /> CONTRACTOR ADDRESS 215 W.Dakota Avenue CITY/STATE/ZIP Clovis,California 93612 <br /> SUBCONTRACTOR Krazan&Associates,Inc. PHONE 559.348.2200 <br /> SUBCONTRACTOR ADDRESS 215 W.Dakota Avenue CITY/STATE/ZIP Clovis,California 93612 <br /> LICENSE VC-57 U C-61 L D-09 ❑Other NUMBER 499908 EXPIRATION DATE 10.31 2019 <br /> DOMESTIC WELL SAMPLING:G General Mineral/Coliform Bacteria(4391)i Dibromochloropropane(4392)CJ Arsenic(4393) <br /> INTENDED USE r�Domestic/Private '-Irrigation/Agricultural D Industrial '.7 Water Quality Monitoring G Soil Sampling/Characterization <br /> J Public Water System <br /> If different from Owner, Water System Name Contact Name or Phone Number <br /> TYPE OF WORK n New Well -I Replacement Well ❑Well Alteration/Modification ❑Other <br /> n Monitoring Well(s) #of wells ❑Soil Boring(s) #of borings Geotechnical 5 #of borings <br /> iJ Out-Of-Service Well D Out-Of-Service Well Renewal D Cross-Connection Repair (10-50 Feet) <br /> D New Pump ❑Pump Replacement ❑Pump Repair G Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method D Mud Rotary D Air Rotary .Auger D Cable Tool ❑Push Point D Other <br /> Proposed Well Depth ft Excavation in diameter ❑Open Bottom I Gravel Pack/Gravel Size in diameter <br /> F)Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad D Steel 11 Plastic i i Stainless Steel i Other <br /> Grout Seal Depth ft /Neat Cement(94 Ib bag/5-10 gal water) 1 Sand Cement sack mix17 gal water <br /> I Bentonite(20%solids) I I Other <br /> Grout Placement Method Ci Pumped i I Free Fall 11 Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By D Driller D Pump Contractor L Other <br /> L1 Concrete Pedestal LDimensions:Width ft Length ft Thick in ❑Christy Box L.Stove Pipe <br /> PUMP n Submersible Turbine D 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 /> UM 4 CE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE Managing Engineer DATE 11%2012018 <br /> GES <br /> �Nv R��pp�,R MENS <br /> D €1 TM ENT USE O Y t� <br /> Application Accepted By to Area Employee ID#IAV v/ <br /> Grout Inspection By AWAZ4,, Date �a �� 1IbbLLPECIA��L Well Permit <br /> Pump Inspection By Date 1 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received <Che Amount Permit/ <br /> Codes Info Cash emitted Date Service Re uest# Invoice# Well ID# <br /> S 2to 'N7'h <br /> EHD 43-06 revised 4/14/18 WELL/PUMP PERMIT <br />