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WELL/PUMP PERMIT <br /> SAN JOAOUIN 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 /> 17401 South Manthe Road Lathrop,CA I» <br /> Joe ADDRESS Y CrrY21P P. <br /> CROs STREET lo'no e Ce4er D f ApN 191-190-610 PARCEL SIZEa'a LAND USE APPLICATION# g <br /> m <br /> OWNER NAME BDDM Investment LLC PHONE <br /> OWNERADORESS 2205 Steinbeck Drive CITY/STATE/ZIP Modesto,CA 95356 <br /> CONTRACTOR Krazan&Associates,Inc. PHONE 559.348.2200 <br /> CONTRACTOR ADDRESS 216W Dakota Avenue CITY/STATIJZIP Clovis.California 93612 <br /> SUBCONTRACTOR Krazan&Associates,Inc. PHONE 559.348.2200 <br /> SUBCONTRACTOR ADDRESS 216 W.Dakota Avenue CITY/STATE/ZIP Clovis,California 93612 <br /> LICENSE /C-57 G-61 -D-09 -Other NUMBER 499608 EXPIRATION DATE 10.31.2022 <br /> --------------- <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 different from Qvmer. Water System Name Contact Name or Phare Number <br /> TYPE OF WORK -New Well - Replacement Well -Well Alteration/Modification ❑Other <br /> -Monitoring Well(s) #of wells _. Soil Boring(s) #of borings f Geotechnical A #of borings <br /> -Out-Of-Service Well -Out-Of-Service Well Renewal Cross-Connection Repair (10-50 Feet) <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 10—S 0 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 Sched -Steel Plastic -Stainless Steel -Other <br /> Grout Seal Depth 10—sD It Neat Cement(94 Ib bag/5-10 gal water) -Sand Cement sack mix17 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method = Pumped Free Fail Other jieffiklit Retardant/Accelerator(name) <br /> PEDESTAL Installed By -Driller -Pump Contractor - Other <br /> -Concrete Pedestal-Dimensions:Width ft Length ft Thick in _ Christy Box -Stove Pipe <br /> PUMP - Submersible--Turbine -Other HP Pump Set ft Standing Water Level k <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. 1 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 /> MIN,INIU"8 H,f�3ir��kADy{/ANtit NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED .y'` f-- TITLE Managing Engineer DATE 05/24/2021 <br /> cYMFNT <br /> L 01 <br /> F/QED <br /> ? 2021 <br /> v PQRT7-CNTy <br /> MFNT <br /> DEPARTMENT USE ONLY <br /> Application Accepted By���[��/�- Date aArea 3 LAM Employee ID# <br /> Grout Inspection By 1't ' � Date ZA _ SPECIAL Well Permit <br /> Pump Inspection By Date _ WAIVER Received <br /> Soil Boring Inspection B Date Constructed yvell Depth ft <br /> COMM z 10 ��, cF tb be i� ; araun WG r ent,�/n der e(l is rlQe�tfYt <br /> PE SC Received Amount Date Permit/ Invoice 0 Well IDG <br /> Codes Into Cas Remitted it Service Request 1. <br /> 376 ISID W1070 <br /> EHD 43-M revised 4/14/18 WELL/PUMP PERMIT <br />