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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 />N -REFUNDABLE PERMIT GALL ZIlIV V041 -16V If FOR INSPECTIONS tAYIKtJ l TtAK tKOM UAIt ISSut ) <br />ADDRESS {(J _.St) J % Vermillion Drive y� CITY/ZIP Stockton, CA <br />SS STREET 1 �'�� �q APN5300� PARCEL SIZE_ LAND USE APPLICATION # <br />IER NAME Delta Community Developers Corp s jj0USjn4 A t ib -111 r 6' PHONE209-460-5042 <br />IER ADDRESS2575 Grand Canal Blvd CITYISTATI /,Stockton, CA 95207 <br />CONTRACTOR Krazan $ Associates, Inc. <br />CONTRACTOR ADDRESS 215 W. Dakota Avenue <br />SUBCONTRACTOR Krazan & Associates, Inc. <br />SUBCONTRACTOR ADDRESS 215 W Dakota Avenue <br />LICENSE /C-57 - C-61 D-09 _ Other <br />PHONE 559.348.2200 <br />CrTYfSTATE/ZIP Clovis, California 93512 <br />PHONE 559.346.2200 <br />CITY/STATE/ZIP Clovis, California 93612 <br />NUMBER 499908 EXPIRATION DATE 14.31.2021 <br />DOMESTIC WELL SAMPLING: General Mineral/COliform Bacteria (4391) _ Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE C Domestic/Private - Irrigation/Agricultural - Industrial Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System <br />If different from Owner: Water System Name Cwtact Name or Phone Number <br />TYPE OF WORK New Well - Replacement Well C Well Alteration/Modification D Other <br />C Monitoring Wells) # of wells D Soil Boring(s) It of boings .I Geotechnical 1 # of borings <br />- Out -Of -Service Well = Out -Of -Service Well Renewal C Cross -Connection Repair (50 Feet) <br />- New PumD ❑ PumD ReDlacement = Pump Repair Raise Well Casing <br />Drilling Method Mud Rotary Air Rotary 4 Auger - Cable Tool - Push Point - Other <br />Proposed Well DepthS;�o_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 _ in Thickness/Gauge/ASTM Schad - Steel ^_ Plastic - Stainless Steel - Other <br />Grout Seal Depth_ It %' Neat Cement (94 1b bagl5-10 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 It 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 1 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. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE 1S <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />MINIMt1M 49 HO ADY NG NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />c-. �j �j �.�( Managing Engineer DATE 02/20/2021 <br />DEPARTMENT USE ONLY <br />Application Accepted By -�/� ,�a� Date 3 a J) '7, <br />Grout Inspection By �_J\I Date T/ <br />Pump Inspection By Date <br />Soil Boring Inspection By Date <br />COMMENTS <br />Area i✓ S Employee ID#� <br />— SPECIAL Well Permit <br />71 WAIVER Received <br />Constructed Well Depth ft <br />EHO'43-46 MOMd 4t14118 WELL /PUMP PERMIT <br />