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i <br /> I <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468 420 <br /> NON-REFUNDABLr 112F0l"IT CALL 09 9$3-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> rn <br /> y <br /> / <br /> JOB ADDRESS ^ 22 CITY1ZJP /�1 Y m <br /> CROSS STREET'�11 �iV 'L� �� �LiP °��0 V' ) <br /> P AIN <br /> p� ARCEL SIZE LAND U APPLICATION!# z <br /> OWNER NAME C Van L—te //\��iJl�t-�V7 1 Cy ���� ryryPttHO��N--��ii��rff�UJ✓Q- 4�—I�� rw^- <br /> OWNER ADDRESS—?0 .yX)K E B00 CITY/STATE/ZIPUh-V�>� <br /> CONTRACTOR CANEPA AND SONS,INC. PHONE (209)532-1136 <br /> CONTRACTOR ADDRESS 14384 CUESTA COURT CITY/STATE/ZIP SONORA,CA 95370 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE �XC-57 ❑C-61 ❑D-09 O Other NUMBER 425749 EXPIRATION DATE 7/31/2020 <br /> DOMESTIC WELL SAMPLING:0 General Mineral/Coliform Bacteria(4391)0 Dibromochloropropane(4392)0 Arsenic(4393) <br /> INTENDED USE D DomesticJPrivate ❑Irrigation/Agricultural Industrial D Water Quality Monitoring ❑Soil Sampling/Characterization P <br /> ❑Public Water System 'rs <br /> If different from Owner: Water System Name Contact Name or Phone Number �� • Cp.� <br /> TYPE OF WORK XNew WeII ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> D MonitoringWell(s) #of wells ❑SoilBoring(s) not borings D Geotechnical #of borings (� <br /> D Out-Of-Service Well ❑Out-Of-Service Well Renewal 0 Cross-Connection Repair KA 1 <br /> ❑New Purnp U Pump Replacement ❑Pump Repair ❑Raise Well Casing20 9 <br /> WELL CONSTRUCTION JO <br /> Drilling Method <br /> )(Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑ Other /V gQU�N <br /> Proposed Well Depth 'U ft Excavation .20 in diameter U Open Bottom YGravel Pack/Gravel Size in da e N�NMFti LINTY <br /> Conductor Casing�in diameter / Conductor Casing Depth 10 ft �EPgRT rk <br /> Weli Casing Diameter in Thickness/Gauge/ASTM Sched 6Z'-C) ,Steel D Plastic ❑Stainless Steel D Other MENT <br /> Grout Seal Depth UU ft ❑Neat Cement(94 1b bag/5-10 gal water) ❑Sand Cement sack mix/7 gal leter <br /> Bentonite(20%solids) ❑Other <br /> Grout Placement Method XPumped ❑Free Fall ❑Other D Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller K Pump Contractor ❑ Other <br /> ❑Concrete Pedestal❑Dimensions:Width ft Length It Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP ❑Submersible❑Turbine ❑Other HP Pump Set ft Standing Water Level ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH S N <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND TIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH LL <br /> WORKERS C P NSATION LAW . <br /> d/l/{ i 4�HAOU AD N E Pt0710E REG2UtRED F R-- JSSPPECF/{�rJ1/]y�S J-/P�LE�ASE CALL(209)953-76970 <br /> SIGNED 1 ✓V! ' TITLE 7 r C.-�!y'C./' vl DATE 10 f 1 <br /> J. <br /> t l <br /> -A <br /> I � <br /> I r4 <br /> I � <br /> 2 <br /> I <br /> EP RTMENT U E O L <br /> Application Accepted By Date Area <br /> Employee ID# <br /> i ISS <br /> Grout Inspection By; Date i c ❑ PECIAL Well Permit <br /> Pump Inspection By Dale ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well De th ft <br /> COMME S <br /> PE SC Received Check#/ Amount Permitif <br /> Code 1 o B' ash a 'ttecl Date Service Req uest# Invoice Weill <br /> V I <br /> I <br /> EHD 43-06 revised 4r1411e /����59 <br /> WELL/PUMP PEi MR <br />