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101/021Z2019 08:26 Canepa & Sons (FAX) P.002/003 <br /> I <br /> I <br /> - WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT1 1868 EAST HAZELTON Av8NU0-SYocicroN CA 95205-(209)4685420 <br /> NON-REFUNDABLE PERMIT CALL 2p9 953-7697 FOR INSPECTIONS EXPIRES T YEAR FROM DATE ISSUED, <br /> JoeADDRrss L3715 0. 111CTmR RO. Crr.y�/MAP d,0r� '�_, Y-57 9 <br /> CROSS SYREET �?0,✓7� R.O/• APN ,'ice-�'��-O�d PARCELSIY �O'ed Vag APPLICATION <br /> OWNERNAME �-""'� !�S/r--+,O T /J PHONk4,,(Y Soo,�0/ <br /> OWNER ADDRESS I r/7� y/`T�/��. CITY/SYATEMF vOOO (A� <br /> CONTRACTOR CANSPA AND SONS,TNC, I PHONE (209)532.1136 <br /> CONTRACTOR ADDRESS 14384 CUBSTA COURT CITYI3TATL/ZIP SONORA,CA 95370 <br /> SUBCONTRACTOR PHONE <br /> SUSCONTRACTOR ADOREsa I COY/SfATROP 1 <br /> LICENSE CaCC-57 Q"1 0 D-09 D Other i NUMBER. _ 423749 EXPIRATION DATE �ie1/2b20 <br /> DomFeTic WELL SAMPLING;U General Mineral/Coliform asteria(4391)0 Dlbromochloropropane(4392)0 Arsenic(4393) , <br /> r�l�DEU3E DornwwPevate. 0 IntpdoNAgrlculturai O.Indurldal Q Water puellty Monitoring 0 Soil Sampling/Chamctertntlon ' <br /> 0 Publlo Water System I ' <br /> If dltrorenl from Owmn Water Byarom Name Contact Name or Phone Number <br /> TYVE OP WORK New Well ,Repleument Well Wall AlteratloNModiflostlon 0 Other �' I <br /> 0 Monitoring Well(s), #of wells O Sol[Boring(s) N or borings0 Gaotochnlcel a w Dainyc, A <br /> 0 Out-Of-Semite Well 0 Out Of-Service Well Renewal C Crmt-Conn"lon Rcpalr 0. ��C� <br /> New PUMP 0 PumR Replacement Q Pump Reoalr 0 Raise Well Casino <br /> WRIU.OPNSTRUCTON nn <br /> Drilling Method ',,Mud PM-, D Air Rotary 0 Agger D Cable Todl 0 Pu:h Point D Other or"r <br /> Proposed Well Depth, _ft Excavedon In diameter 0 Open Bottom Gravel Pack/Grovel Size- ^in dlanv 3 <br /> 0 Conduct-1.asing In diameter y Conductor Casing Depth— R , H ✓/QgQtj, 4919 <br /> Well CaSing Diameter ;n ThlckncWGaug*/ASTM Schad L 0 Steel '1as40 D Stainless Steel D Other' "'yo HC <br /> Grout Seal Depth— —ft D Neal Cement 410 BDg a70 gal water) 0 Send Cement Sao m/x17 gal water 1HO�pMFN��NT <br /> 3entaNflA i?09'6 Codd&) 0 Otho r gRTM'94 'r <br /> Grout Placemoni method '.r ed Q Free Fall 0 0th r 0 Retardant/Aceelera:or(name) ANT <br /> aTAL I wtalled By 0 Driller ImTp Contra or 0 Other <br /> Concrete Pedestal DDI enslons;Width fl Length��a h Tnick M 0 Chris Box ❑Sto a Pipe j <br /> P o SUhmerslble❑Turbine 0 Other HP Pump Se -.V R Stand nQ Water Level ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS AP, LIGATION AND THAT TWE'WORK WILL HE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND FULES AND REGULATIONS. I"ALs;Q CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTtzACTQRS STATE LICENSE GOJ AND THAT I AM,IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS, <br /> Ml U HOUR ADVANCE NOTICE REQUIRED FQRtyrNSPECTIONS-1'I.EA$E CALL(209)953.76-9, <br /> SIONBD I TITLE ^' '0' Nr DATE <br /> F 17 <br /> uy's� <br /> I' <br /> x „ <br /> i <br /> I ' <br /> I <br /> I b <br /> I <br /> P TMENT UFIE RNLY <br /> AppBcation Accepted D beta11)A1119 Area ` ` Emplcyce ID# <br /> Grout Inspection By Date ❑ SPECIAL Woil Permit <br /> Pump Inapoctlon By r Date 0 WAIVER Recolved <br /> Soli Boring Inapecgon By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Ro-;vivcd alinkM Am unt Permit/ <br /> o Info 8 P Cash pernirted, Date -$—NoRv ue-t# Invoice# Well ID# <br /> a 015 a <br /> I <br /> ��'��Rece1vzd TilTe-0c t, 2, _2019-- 3 : 22ANLNo, 5537 <br />