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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232 (209)468-3420 <br /> NON-REFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 10351 E. Acam o Road CITY/ZIP Acampo 95220 m <br /> D <br /> CROSS STREET Tretheway Road APN 017-180-10 PARCEL SIZE 75.40 LAND USE APPLICATION#PA-1800170 0 <br /> o ra <br /> OWNER NAME BrettftLagorio, et al PHONE 209-351-1220 m <br /> OWNER ADDRESS 20001 E. Flood Road CITY/STATE/ZIP Linden, CA 95236 <br /> CONTRACTOR N/A PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP <br /> LICENSE ❑ C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER EXPIRATION DATE <br /> BILLING PARTY: ❑OWNER ❑CONTRACTOR ❑ SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:0 General Mineral/Coliform Bacteria(4391)0 Dibromochloropropane(4392)0 Arsenic(4393) <br /> INTENDED USE 0 Domestic/Private 0 Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> ❑ Public Water System hA� <br /> If different from Owner: Water System Name Contact Name or Phone Number !r <br /> TYPE OF WORK ❑ New Well 0 Replacement Well 0 Well Alteration/Modification 0 Other <br /> 0 Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of b/orrings—� <br /> X Out-Of-Service Well 0 Out-Of-Service Well Renewal 0 Cross-Connection Repair 4Ut7 y <br /> ❑ New Pump ❑ Pump Replacement ❑ Pump Repair 0 Raise Well Casing20' <br /> WELL CONSTRUCTION H EM'�AO UlN C U <br /> Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ push Point ❑ OtherTH nc� '/V7-A, <br /> Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size In <br /> 0 Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched 0 Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth ft 0 Neat Cement(94 Ib bagJ5-10 gal water) ❑ Sand Cement sack mix17 gal water <br /> 0 Bentonite(20%solids) ❑ Other <br /> Grout Placement Method ❑ Pumped ❑ Free Fall 0 Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By 0 Driller ❑ Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal❑Dimensions:Width ft Length ft 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 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 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS, <br /> MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL(209) 953-7697 <br /> SIGNED TITLE Civil Engineer DATE Aug. 23, 2019 <br /> gr Irs <br /> 1 <br /> E PARTMENT E ONLY <br /> Application Accepted By 1 _ Date _v7 Area Employee ID#� <br /> Grout Inspection By f Date U PECIAL Well Permit <br /> Pump Inspection By Date CI WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS mjr-- C2Vveli 5 seairct on2oerk <br /> PE SC Received Check#/ Amount DatePermit/ Invoice# Well ID# <br /> Codes Info B as Remitted Aervice,R u st# <br /> EHD 43-06 6/11/2619 WELL/PUMP PERMIT <br />