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r 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 /> N <br /> Joe ADDRESS 2900 Ffeiront Street CITY/ Stockton CA m <br /> -s o <br /> CROSS STREET APN PI RCEL SIZE LAND USE APPLICATION# <br /> m <br /> ATC Design Group160738-8000 '^ <br /> OWNER NAME PHONE 41 <br /> OWNER ADDRESS 1282 Pacific Oaks Place Suite CCI TY/ 7 E/LP Esronrlidli,CA 92029 <br /> CONTRACTOR Krazan&Associates.Inc. PHONE 559.348 2200 <br /> CONTRACTOR ADDRESS 215W Dakota Avenue. CITY/STATEIZJP Clovis,California 93612 <br /> SUBCONTRACTOR K',azan&Associates.Inr PHONE 559.348.2200 <br /> SUBCONTRACTOR ADDRESS 215W Dakola Avenue CITY/STATE/ZJP Clovis,Caldnrnia 93612 <br /> LJCENSE /C-57 C-61 D-09 Othef NUMBER ,I"908 EXPIRATION DATE 10•17.2019 <br /> DOMESTIC WELL SAMPLING:''- General Mineral/Coliform Bacteria(4391)❑Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private - Irrigation/Agricultural -Industrial O Water Quality Monitoring Soil Sampling/Charactenzation <br /> Public Water System <br /> If different from Owner Water System Name Contact Name or Phone Numoer <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Il Other <br /> MonitoringWell(s) #of wells -:Soil Bodng(s) 0ofborings (Geotechnical 0ofboring, <br /> Out-Of-Service Well D Out-Of-Service Well Renewal O Cross-Connection Repair (10-00 Feel) <br /> New Pump Pump Replacement ❑Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary -Air Rotary V Auger --Cable Tool Push Point Other <br /> Proposed Well Depth It Excavation in diameter -Open Bottom Gravel Pack/Gravel Size in diameter <br /> 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 VNeat Cement(94 lb bag/5-10 gal wafer) Sand Cement sack mtxr7 gal water <br /> Bentonite(20%solids) ❑Other <br /> Grout Placement Method Pumped I Free Fell Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By �Driller 17 Pump Contractor - Other <br /> ❑Concrete Pedestal Dimensions:Width ft Length it Thick in Christy Box Stove Pipe <br /> Pu MP C Submersible Turbine Other HP Pump Sel ft Standing Water Level­9 <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 /> SIGN E TITLE Managing Engineer DATE 11 20/201P <br /> GES <br /> 6 1p1� <br /> N�0` 0 ME�ZMENt <br /> \j\A p z <br /> 'f(/(//�� =Ie <br /> N T <br /> Application Accepted By J Area�_LC�(� Employee ID# <br /> Grout Inspection By G�' / Date ell Permit <br /> Pump Inspection By Dale WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received <_2Lqj0UW Amount Permit/ <br /> Codes Info Cash Ftemitted I Date Service Request# Invoice# Well ID# <br /> S46,11 i� <br /> EHO 13-08 rlvir.d 4/14/18 WELL RUMP RERMn <br />