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/ 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 <br /> Grant Line Road and Corral Hollow Road "ITY/ZIP Tracy,CA y <br /> D <br /> CROSS STREET (e9; APN 2 9-04 g,40Z _....E LAND USE APPLICATION# a <br /> Partner Engineering&Science 610-220-6173 m <br /> OWNER NAME PHONE vi <br /> OWNER ADDRESS 2154 Torrance Boulevard,Suite 200 CITY/STATE/ZIP Torrance,CA 90501 <br /> CONTRACTOR Krazan&Associates,Inc. PHONE 559.348.2200 <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 CITYISTATE/ZJP Clovis,California 93612 <br /> LICENSE VC-57 ❑C-61 ❑D-09 ❑Other NUMBER 499908 EXPIRATION DATE 10.31.2020 <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)❑Dibromochloropropane(4392)U Arsenic(4393) <br /> INTENDED USE ❑Domestic/Private ❑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 /> ❑MonitoringWell(s) #of wells ❑SoilBoring(s) #of borings -1 Geotechnical 8 #ofborings <br /> D Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair (5-25 Feet) <br /> ❑New Pump ❑Pump Replacement ❑Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary Auger ❑Cable Tool 0 Push Point ❑ Other <br /> Proposed Well Depth ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> [l Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth ft .Neal Cement(94/b bag/5-10 gal wafer) ❑Sand Cement sack mix/7 gal water <br /> ❑Bentonite(20%solids) ❑Other <br /> Grout Placement Method ❑Pumped Free Fall Fj Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> ❑Concrete Pedestal Cl Dimensions:Width ft Length ft 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 /> -MINIMUM 4 U NCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIG TITLE Managing Engineer DATE 02/14/2019 <br /> Sul �5 44 <br /> Vol <br /> DEP TMENT U`SSE O <br /> Application Accepted By Date 2 `�/G+✓ J Area t Employee ID#�� <br /> Grout Inspection ByDate i' 1 SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By , Date Constructed Well Depth It <br /> COMMENTS 1 <br /> PE SC Received hecMW Amount Permitt <br /> CodesInfo B ash RemittedDate Service Re uest# Invoice# Well ID# <br /> 3 "l o Z 4 UID <br /> EHD 43-08 revised 4/14/18 WELL/PUMP PERMIT <br />