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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 /> NON-RFFIINnARI F PFRMIT CALL 2099)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> _. <br /> JOBADDROG S 011/1Aevsr /2?Ae 'e • CITVIZIP IRA/ , 95py-d <br /> 1/ �,f ) 'p>� �/ a <br /> CROSS STREET l�k7-r-C'e%,�Nr ' APN 05/ P4a 1&,P PARCEL SIZEWi�LAND USE <br /> APPLICATION# +nom A <br /> OWNERNAME `��k� �t1F�T/�L�k J U 14,fVJK „HONE 6?je .o1J'1 I��� <br /> OWNER ADDRESS 7S •rr* `-"ACV ST �C-1 7 I`�L s` CrTYfSTATE/ZIP / <br /> CONTRACTOR CANEPA AND SONS,INC. PHONE (209)532-1136 <br /> CONTRACTOR ADDRESS 14384 CUESTA COURT Cm/STATE2IP SONORA,CA 95370 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE INC-57 0 C-61 ❑D-09 ❑Other NUMBER 425749 EXPIRATION DATE 7/31/2020 <br /> DoMEST1C WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)❑Dibromochloropropane(4392)D Arsenic(4393) <br /> INTENDED USE nestic(Private Irrigafion/Agdcultural ❑Industrial ❑Water Quality Monitoring D Soil Sampling/Characterization <br /> D Public Water System <br /> It different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well X Replacement Well 0 Well Alteration/Modification n Other <br /> 0 Monitoring Well(s) #of wells ❑Soil Boring(s) Nofborngs D Geotechnical ><ofborings <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ❑New Pump O Pump Replacement 0 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 `C fl� It Excavation Im in diameter ❑Open Bottom ),Gravel Pack/Gravel Size 3 in diameter <br /> ❑Conductor Casing in diameter / Condurtn,P• -ig Do-4h ft <br /> Well Casing Diameter I in Thi77 clrness/Gauge/ASTM Sdted y� heel Mastic ❑Stainle«Q� ' 7 Other <br /> Grout Seal 'Depth 1 ❑Neat Cement(94!b bag/ 10 gal water) -Send Cement_ _sack m1xf7 gal water <br /> y5 lentonite(20%solid=' ❑Other <br /> Grout Placemenf method Pumped Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller Pump Contractor ❑ Other <br /> ❑Concrete Pedestal❑Dimensions:Width ft Length If Thick in ❑Christy Box D Stove Pipe <br /> PUMP 0 Submersible❑Turbine ❑Other HP Pump Set It Standing Water Level ft <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 /> WORKERSCO PENSATION LAWS. <br /> P11 48 b C(�UR ADVANCE NOTICE REQUIRED FOR (/PEECC/TfIIONS-PLEASE CALL 209 P9§3-7V7 <br /> SIGNED TITLEf /' DATE <br /> ! ! i <br /> T WE <br /> / <br /> A <br /> a <br /> - e <br /> DEPA TMENT SE ONLY <br /> Application Accepted By Date Area Employee ID# <br /> Grout Inspection By Date ❑ PECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Igpection By ate Constructed Well Depth <br /> COMMENTS n TO / rN &Cf g ,fid/V <br /> PE SC Received Check#/ Amount Permit/ Invoice# Well ID# <br /> Codes jEfo B Service Re u s #gash RemittedDat <br /> I <br /> liy EHD 4346 raviseo 4114/18 /���LL2� WELLMUMP PERMIT <br />