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t ` <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 L 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Jos ADDRESS -1223 Austin Roan CITY/LP h�;on C:•. 2' <br /> M <br /> D <br /> CROSS STREET / ( APN 226-150-021 PARCEL SIZE-3tAND USE APPLICATION# v <br /> r �)� A, ), A <br /> OWNER NAME I;edrlk'S Nur5Cry I F'{/�l 4 KS (PAV ID PHONE H <br /> OWNER ADDRESS 23223 5.Austin Road i '~ CITY/STATFJLP Ripon.California <br /> CONTRACTOR Krazan R Associates,Inc. PHONE 559.348.2200 <br /> CONTRACTOR ADDRESS 215W Dakota Avenue CITY/STATE/LP ('IOVI<,California 93512 <br /> SUBCONTRACTOR Kra[an 8 Associates.Inc. PHONE 559.348 2200 <br /> SUBCONTRACTOR ADDRESS 215 W Dakola Avenue CITY/STATE/ZIP Clovis.California 93612 <br /> LICENSE C-57 C-61 D-09 i Other NUMBER 4gyy�n`. EXPIRATION DATE—'()"f'2018 <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If ciiflerent 1—Owner Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well Replacement Well Well AJteration/Modification Other <br /> Monitoring Well(s) #of wells Soil Boring(s) o of bo"nes ✓Geotechnical3 0 o borings <br /> Oul-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair Geotechnical—3- <br /> New Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary ./Auger Cable Tool Push Point Other <br /> Proposed Well Depth�1709 If 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 Schad Steel Plastic Stainless Steel Other <br /> Grout Seal Depth(!5 - O It /Neat Cement(94 Ib bag/5-10 gal water) Sand Cement sack mrxf7 gal water <br /> Bentonile(20%solids) Other <br /> Grout Placement Method Pumped Free FallOther 't% Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller I Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width ft Length ft Thick in Christy Box Stove Pipe <br /> PUMP Submersible Turbine i Other HP Pump Set If Standing Water Level R <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 /> -L411NINIU141 4E UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNE TITLE P°t,m•r._liny CnJu in,�r DATE U412G','201;5 <br /> MENT <br /> IVF <br /> 82018 <br /> NTUo-y <br /> AC <br /> T'�FMT <br /> WPA T M ENT U E O L / / <br /> Application Accepted By D to Area'�'� Employee ID# � <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Dale WAIVER Received <br /> Soil Boring Inspection Byc-� Data L' / Constructed Well Depth ft <br /> COMMENTS L.' <br /> PE SC Received Check# Amount Date Permitt Invoice# Well ID# <br /> 4 <br /> Codes Info Remitted ervic Request# <br /> O z1a 21 442S <br /> EHC 43-06 rif—al 4/14/18 WELL/PUMP PERMIT <br />