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I <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT I 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205•(209)468.3420 <br /> NON-REFUNDABLE PERMIT r �/ CALL 209 953-7697 FOR INSPECTIONS EXPIRESS�I YEAR FROM DATE ISSUED <br /> Joe ADDRESS �^• V/e Tmk RD. CITY/7JP 649,01 L,r/�7 ✓`Io��® <br /> Q i rRo oisdF n <br /> CROSS STREET P�j���1!1.2y/ APN�`J r"�^-0'zA�/!� PgRCEL SrLE LAND USE APPLICATION�J# p <br /> OWNER NAME "'�' `sTe�o�- II PHONE(Aff 5007-�[�6'/0 N <br /> OWNER ADDRESS VI GTo� r�D CITY/STATE/ZIP oDO N� ?V A/ O <br /> CONTRACTOR CANEPA AND SONS,INC. I PHONE (209)532-1136 <br /> CONTRACTOR ADDRESS 14384 CUESTA COURT CITY/STATEZP SONORA,CA 95370 <br /> SUBCONTRACTOR I PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP•� <br /> LICENSE XC-57 0 C-61 0 D-09 0 Other I NUMBER 425749 EXPIRATION DATE 7/31/2020 <br /> DOMESTIC WELL SAMPLING.0 General Mineral/Coliform(acteria(4391)0 Dibromochloropropane(4392)0 Ars nic(4393) <br /> INTENDED USE 9e DomestictPrivate 0 Irrigation/Agricultural 0 Industrial 0 Water Quality Monitoring 0 Soil Sampling/Characterization - <br /> 0 Public Water System <br /> 11 different from Owner. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well XReplacement Well Well Alteration/Modification 0 Other <br /> 0 Monitoring Well(s) #of wells Soli Bofing(s) PA#of botings 0 Geotechnical #of borings <br /> 0 Out-Of-Service Well 0 Out-Of-Service Well Renewal D Cross-Connection Repair R��I��,I� T <br /> 0 New Pum 0 Pum Replacement 0 Pum Repair 0 Raise Well CasingC® <br /> WELL CONSTRUCTION ^ <br /> Drilling Method XMud R ary 0 Air Rotary 0 Auger O Al8 c <br /> Cable Tool 0 Push Point 0 Other 8 05 <br /> 2019 Proposed Well Depth 00 It Excavation in diameter 0 Open.Bottom t.Gravel Pack/Gravel Size �1 In diam <br /> 0 Conductor Casing in diameter Conductor Casing Depth ft . Qjj/N <br /> Well Casing Diameter 40 in Thickness/Gauge/ASTM shed l/i7 v) 0 Steel Plastic 0 Stainless Steel D Other V�R0NM COUN71' <br /> Grout Seat Depth 19Q ft 0 Neat Cement 4 Ib bag/5-10 gal water) 0 Sand Cement sack mixl7 gal water TH�fPA FMrAC <br /> Bentonite(20%solids) 0 Other R �(V71 <br /> Grout Placemen Method pumped 0 Free Fail 0 Other 0 Retardant I Accelerator(name) <br /> PEDESTAL Installed By 0 Driller Pump Contractor 0 Other <br /> 0 Concrete Pedestal ODimensloris:Width ft Length ft Thick in 0 Christy Box 0 Stove Pipe <br /> PUMP 0 SubmersibleD Turbine 0 Other HP Pump Set ft Standing Water Level ft <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APbLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND gULES 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 /> WORKERS COMPENSATION LAWS. <br /> Mf U HOUR ADVANCE NOTICE REQUIRED FOR,�NSrPECTIONS-PLEASE CALL(209)95 76971 <br /> SIGNED I TITLE `O DATE <br /> I <br /> I � r <br /> i <br /> p I <br /> i <br /> I a <br /> I <br /> i <br /> p�1 TMENT U E ONLY <br /> Application Accepted By It-71 I I I <br /> ate Area Employee ID#�� <br /> Grout Inspection By Date Z ❑ SPECIAL Well Permit <br /> Pump Inspection By Data 0 WAIVER Received <br /> Soil Boring Inspection By I Date Constru d Well Depth ft <br /> CO MENTS I - <br /> I <br /> PE SC Received Check#/ Amount Permit/Codes Info ash emitted bate Service Re uest# Invoice# Well ID# <br /> L <br /> Oa <br /> Un <br /> J EHD 43-06 rovised 4/14/18 �!/j�� (�„� R,7&500 WELL/PUMP PERMIT <br />