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WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)4683420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS Co, EXPIRES 1 YEAR FROM DATE ISSUED <br /> �e �'' <br /> JOB ADDRESS �'�� ti �r> ' N- 0 <br /> mZP Gp4!F/!�l�NTS,G,�I . J� ,77 m <br /> j �A Q p / D <br /> CROSS STREET / Y AP�NiOO j'O jO-1;W—e4O PARCEL SIZE006 LAND USE APPLICATION <br /> OWNER NAME M14AA0Z frOl/'Q/6T.WG- <br /> i/ [j/.�[//,t/5 PHONEGKles9Q1 <br /> OWNERADORESS Z11SOO P491*, 42E69 /Wr• CITYISTATEMPC7/4LT' �A. -x ff <br /> CONTRACTOR CANEPA AND SONS,INC. PHONE (209)532-1136 <br /> CONTRACTOR ADDRESS 14384 CUESTA COURT CITY/STATE/LP SONORA,CA 95370 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATEZP <br /> LICENSE IXC-57 D C-61 0 D-09 Other <br /> -f& NUMBER 425749 EXPIRATION DATE 7/31/2020 <br /> DOMESTIC WELL SAMPLING:D General Mineral/Coliform Bacteria(4391)D Dibromochloropropane(4392)D Arsenic(4393) <br /> INTENDED USE D DomestidPrivate rrigation/Agricultural 0 Industrial 0 Water Quality Monitoring ❑Soil Sampling/Characterization <br /> D Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK YNew Well ❑Replacement Well 0 Well Alteration/Modification D Other <br /> i <br /> 0 Monitoring Well(s) of wells 0 Soil Boring(s) Oofbodngs 0 Geotechnical #or borings <br /> C Out-Of-Service Well 0 Out-Of-Service Well Renewal 0 Cross-Connection Repair <br /> 0 New Pump 0 Pum Re lacement ❑Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method' Mud Rotary ❑Air Rotary 0 Auger 0 Cable Tool 0 Push Point 0 Other <br /> Proposed Well Depth J ft Excavation 2 in diameter ❑Open Bo Gravel Pack/Gravel Size 3 3 R in diameter <br /> ❑Conductor�C�asing—in diameter / Conductor Casing Depth It i <br /> Well Casing Diameter 10 in Thickness/Gauge/ASTM Sched t 2—'50 J����"""Steel „0 Plastic 0 Stainless Steel ❑Other <br /> Grout Seal Depth C 1It 0 Neat Cement(94 lb bag/5-10 gal wal€l) and Cement 9 I sack mix(7 gal water <br /> ❑Bentonite(20%solids) 0 Other <br /> Grout Placement MethodX Pumped ❑Free Fall 0 Other 0 Retardant/Accelerator(name) <br /> PEDESTAL Installed By 0 Driller XPump Contractor ❑ Other <br /> 0 Concrete Pedestal❑D rrtensions:Width ft Length It Thick in 0 Christy Box 0 Stove Pipe <br /> i. <br /> PUMP ❑Submersible❑Turbine 17 Other HP Pump Set It 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 A JD <br /> /j�TIVE WIrA�7 <br /> CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM.IN COMPLIANCE WITH ALL <br /> WORKERS OMPENSATION <br /> J' lM.//4J�fu•ONCE NOTICE REQUIRED FO—R--[N, PEC(J'h^OASq-PLEASE CALL(209)9 7 9 <br /> SIGNED . Vr%/A�,..s'� <br /> TITLE_ li DATE 4-.•. <br /> ----- -- : f/ SAY <br /> o '�Fc MFNr <br /> oal <br /> $NV qQe 2019 <br /> ' �Ma <br /> 00,462PA TMENT SE ONLY <br /> Application Accepted By ate� Area_' Employee ID# <br /> Grout Inspection By lti9 Date /ff—� r ❑ SPECIAL WBII Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection B� - Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Cods I o Cash Re fitted Service Re nest# <br /> sem- Z� a <br /> R <br /> 1 <br /> EHO 43-06 revised 4/14118 WELL/PUMP PERMR <br />