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V <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PPEER�RMIT '' ff,, CALL 209 953-7697 FOR INSPECTIONS EXPIRES <br /> �1gYEAR <br /> pFRROOM DATE ISSUED <br /> W <br /> JOB ADDRESS -�+7t�"-v e ura k CITYIZIP Ir7 <br /> 'J�)^/ 13CROSS$TREET�etTeV APN D <br /> �o PARCEL SIZE LAND USE # <br /> yOWNER NAME PHOON6ffl —/ 1Q <br /> OWNER ADDRESS A iI& A <br /> CITY/STATEl7iP 6�f' C.l fG.(/ —/��d—i✓ <br /> CONTRACTOR CANEPA AND SONS,INC. PHONE (209)532-1136 <br /> CONTRACTOR ADDRESS 14384 CUESTA COURT Cm/STATEILP SONORA,CA 95370 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATEIZIP <br /> LICENSE CtC-57 D C-61 0 D-09 D Other NUMBER 425749 EXPIRATION DATE 7/31/2020 <br /> DOMESTIC WELL SAMPLING:O General Mineral/Coliform Bacteria(4391)D Dibromochloropropane(4392)D Arsenic(4393) <br /> INTENDED USE 0 Domestc;Wvate Irrigation/Agricultural 0 Industrial D Water Quality Monitoring 0 Soil Sampling/Characterization <br /> 0 Public Water System <br /> If different from Owner. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK 0 New Well Replacement Well 0 Well Aiteration/Modification 0 Other <br /> 0 Monitoring Well(s) #at wells ❑Soil Boring(s) #of borings 0 Geotechnical #ofborings <br /> 0 Out-Of--Service Well 0 Out-Of-Service Well Renewal O Cross-Connection Repair <br /> 0 New Pump ❑Pump Replacement 0 Pump Repair 0 Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method)KMud Rotary D Air Rotary 0 Auger 0 Cable Tool 0 Push Point ❑ Other <br /> Proposed Well Depth ft t n_D in diameter 0 Open Bottom Gravel Pack/Gravel Size in diameter <br /> 0 Conductor Casing I meter / Conductor Casing Depth ft <br /> Well Casing Diameter L In 0FSstGauaelASTM Schad y1 ❑Steel Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth ft D Neat Cement(94 Ib bag/5-10 gal water) 0 Sand Cement sack mbd7 gal water <br /> Bentonite tcvA solids) 0 Other <br /> Grout Placement Method Wumped 0 Free Fall 0 Other 0 Retardant I Accelerator(name) <br /> PEDESTAL Installed By D Driller ump Contractor ❑ Other <br /> O Concrete Pedestal ODimensions:Width It Length ft Thick in 0 Christy Box 0 Stove Pipe <br /> PUMP 0 Submersible0 Turbine ❑Other HP Pump Set ft Standing Water Level ft <br /> 1 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 AW ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS PENSATION LAWS. <br /> I N>'U 48 R ADVANCE NOTICE REQUIRED F0 I P TIO -P SE CALL(209b9 7-7y/� <br /> SIGNED TITLE DATE11 (l <br /> R gYM-10R <br /> .5CAIC10-' 400 <br /> FCF�V�T <br /> IQ41/�y Of9 <br /> ry0. � <br /> AR�H <br /> i <br /> FNr <br /> PA 7MENT U_aJE N L Y <br /> Application Accepted By te Area4noll <br /> Employee ID#1 � <br /> Grout Inspection By Date l Permit <br /> Pump Inspection By Date 0 WAIVER Received <br /> Soil Boring In pection By Date Constructed Well Depth . <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes fo ash emitted Service Re est# <br /> EHD 43-06 revised 4/14/18 WELL/PUMP PERMfr <br />