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0 Submersible0 Turbine El Other HP Pump Set ft Standing Water Level ft PUMP <br />JOB ADDRESS crryalp Lathrop, CA 1757 L.414 e Rd. <br />Clovis, CA 93612 CITY/STATE/ZIP 215 W. Dakota Avenue SUBCONTRACTOR ADDRESS <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />TYPE OF WORK 0 New Well 0 Replacement Well 0 Well Alteration/Modification 0 Other <br />O Monitoring Well(s) 4 of wells El Soil Boring(s) # of borings X Geotechnical 2 # of borings <br />5 Out-Of-Service Well 0 Out-Of-Service Well Renewal Cl Cross-Connection Repair (10-50 Peet) <br />New Pump LI Pump Replacement 0 Pump Repair E Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method Mud Rotary 0 Air Rotary 0 Auger 0 Cable Tool 0 Push Point El Other <br />Proposed Well Depth -TD ft Excavation in diameter C Open Bottom D Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched E Steel Ei] Plastic El Stainless Steel Li Other <br />Grout Seal Depth b --g-1) ft x Neat Cement (94/b bag/5-10 gal water) D Sand Cement sack mix17 gal water <br />Bentonite (20% solids) 0 Other <br />Grout Placement Method El Pumped LI Free Fall LI Other U Retardant / Accelerator (name) <br />CROSS STREETS) I r3 Levee ApN q004 PARCEL SIZEI31 LAND USE APPLICATION # <br />OWNER NAME Union Island Mutual Water Company PHONE <br />OWNER ADDRESS 2181 N. Tracy Blvd #203 Cry/STATE/ZIP Tracy, CA 95376 <br />Krazan & Associates, Inc 559-348-2200 <br />CONTRACTOR PHONE <br />215W. Dakota Avenue Clovis, CA 93612 <br />CONTRACTOR ADDRESS Crry/STATp <br />SUBCONTRACTOR Krazan & Assoviates, Inc PHONE 559-348-2200 <br />LICENSE X C-57 , C-61 C D-09 U Other NUMBER 499908 EXPIRATION DATE 10.31.2022 <br /> <br />Domestic/Private El Irrigation/Agricultural El Industrial U Water Quality Monitoring El Soil Sampling/Characterization <br />D Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />INTENDED USE <br />PEDESTAL Installed By 0 Driller 0 Pump Contractor !I' Other <br />0 Concrete Pedestal ODimensions: Width ft Length ft Thick <br />in 0 Christy Box 0 Stove Pipe <br />WELL/PUMP PERMIT <br />SAN jOAOLIIN 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 />Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect to the following items: GPS <br />Coordinates, property lines, adjoining properties, water bodies or courses, drainage pattern, roads, existing wells, structures, <br />potential sources of contamination, sewers or private disposal systems. Include distance from two property lines. For Domestic, <br />Agriculture, Industrial well, provide location of any water wells or surface water within 200' radius of proposed well. <br />MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />DEPARTMENT USE ONLY <br /> <br />Application Accepted By 4-4..-Date S ,?_49 Area ./.(f(ie <br />, Employee ID# AS <br /> <br />Grout Inspection By Date Ii SPECIAL Well Permit <br /> <br />Pump Inspection By Date WAIVER Received <br />Soil Boring Inspection By Date _5_1131-72_. Constructed Well Depth ft <br />COMMENTS lierY% I e -). tae. uSe i-r deeper thetri 30 teef or ic5iDuriciwgi <br />entadrifercsici 4 Vote *ittletrit4. .J <br />PE <br />Codes <br />SC <br />Info <br />Received <br />By <br />ie,ase <br />s <br />Amount <br />Remitted <br />Permit/ <br />, Date I 1 Service Request # <br />APD, Invoice # - <br />--• %I <br />" 2 rwiii ID# <br />437d iso CW1(1-35P--q2) “.0 8 L4 /Z5/.2l W22- sAN ii;LoAQL,_ " Z022 <br />he447 0mip- qc <br />ilv co <br /> uNry pArt,44 <br />' ENT <br />EHD043-06 0407F2022 Well Pomp Permit Page I of 2