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Dzc, 15. 2017 9; 15AM Canepa & Sons No, 03966 <br />WELL/PUMP PERMIT P <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 186BEA13THAZELTON AVENUE • STOCKTON CA95205 - (209)468-3420 <br />NON-REFUNDABLE PERMIT CALL 208 863.7697 FOR IN$PEC11ONS P-XPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS -W53 N. CORD ROAD clTY21P - <br />CROSSSTREET 1jjCjLj VAY 12 APN 023,15n.4II PARCELSIZE822Q5 LAND UgE APPLICATIONS <br />OWNER NAME -,)CARL MICHAEL AND LISA /' PNONe.(209)327-4771 <br />OWNER ADDRESS 20 BOX 2240 CITY/STATE/ZIP_LQ 21' S7 <br />CONTRACTOR C PHONE <br />(209) 532-1136 <br />CONTRACTOR ADDRESS CITYISTATE/ZIb �()NORA 95370 <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS CITY/STATEIZIP (j <br />LICENSE -57 D C-61 D 0-09 Other NUMBER 4ZS7L / EXPIRATION DATE I <br />OOMESTIC WELL SAMPLING;! General Mineral/Coliform Bacteria (439 1) i i Dibromochloropropane (4397,) 1 I Arsenic (4393) <br />INTENDED U9E D DomaslldPrlveIe �rrigalion/A9rICUllurel G IndUslrial O Water Quality Monitoring IJ Soil Sampling/Characlerizalion <br />Public Water System <br />If 6lxcrcnl Rom Owner' Wdtdt vy6lem Name Conlgtl Nemo or Pnbno N�mbar <br />]Y'ZE OF WORK <br />PAYMENT <br />RECEIVED <br />EONtMEx <br />HEXI_TF1 DEPAR <br />93b� <br />7,New well Kaploeement Well D Well AlleretlonfMocIftalion G Other <br />Monitoring Wallis) #olwells DSoil Borina(S) 0ofboAr'os UGeo(echnlcal aofbonnos <br />�] Oul-Or-Service Well C Out -Of -Service Well Renewal D CrOSS-Conneclion Repeir <br />Drilling Method X Mud Rotary I., Air Rotary D Auger p Cable Tool 177 Push Point ❑ Other <br />Proposed Well Depth JS60 it Excavation 21� In diameter U Open Bottom (Gravel Pack/Gravel Size In diameter <br />Conductor Casing in diameter / ConductorC,aeing Depth ft <br />Well Casing Diameter 1z in Thickness/Gauge/ASTM Schad -LV I<Slaal n Plastic 11 Slainlars Steel sg1.1 Other <br />Grout Seel Depth rZ O It 0 Neel Cement (94 Ib bag/6-90 gel wafer) )Cend Cement 40 ..7 �seck mix 7 gal water <br />u Benlonile(20% solids) 0 Other <br />Grout Placement Method Pumped D Free Fall U Other D Retardant / Accelerator (name) <br />PEDESTAL Installed By D Driller . Pump Contractor D Other <br />Concrete Pedealal CDlmensions: Width 11 Langih R Thick In Christy Box D StOVe Pipe <br />AP SuDmeralbtal Tu bine n OIRe! HP Pump Sel fL Standing Water Level fl <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 ATIVIE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS CO ATION LAW& <br />MIPPUH I NCE TrcE REQUIRED rris'� TIOnN�S -PLEASE CALL (209) <br />SIGNED 71%6— 4y3 t]J — DATE _ <br />�R T M E N T U 9 E ONLY <br />Application Accepted By // Dale f� <br />Area ` Cj� Employee IDK <br />WO n <br />Grout Inspection By <br />Dete O <br />❑ SPECIAL Well Permit <br />Pump Inspection By . <br />I <br />Dele <br />1..) WAIVER Raceived <br />Sol) Boring Inspection By , - <br />Dale <br />Constructed Wall Depth <br />it <br />COMMENTS GQfMs 422"6--J4411 <br />PE SC Received Checkrl/ <br />Godee Into Cash <br />Amount Dale <br />Remitted <br />Permed Invoice p Well IDp <br />Sarvlce Request R <br />0 <br />3r. jAq091t <br />1 DD - 01 <br />EHD43-W amine WELL IPUAP PER MIT <br />Recelved Time Dec, 15. 2017 9.26AM No. 2729 3� <br />11 ave <br />CIV® <br />13' 2017 <br />HEALTH <br />