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09/14/2018 0';52 Canepa & Sons (FAX) P.002/010 <br /> WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNT'E%mRovz ENTAL HEALTH❑EPARTmewr :868 EAaT HAZELTON AVENUE•S'oCKToN CA 95205-(209)411-34220 <br /> NON-REFUNDABLE PERMIT CAL 09 963-7697 FOR INSPECTIONS /EXPIRES 1 YEAR l DATE ISSUED <br /> .r <br /> iJOB ADDREss aTr17Ja 'f ' M <br /> �J �� <br /> CR=STRPF APN iJt1 1 '31 PARCEL SIZE .kl; Nu aI-CATION V ! c <br /> OsW <br /> OWNR NArae �± �.y�ahl N, 1�i ids `T `,� 1P)32-7/y--- <br /> jOV&ER ADaRE93 J Qr�F.f '�tHT�'r+NfM7f�P '� i <br /> ICONTwuroA CANEPA AND SONS,INC. PHONE (209)SV2-1;36 <br /> CONTRACTOR ADORE= 14384 CUFSTA COURT CrTWr Tj2 SON'01 Ak CA 95370 <br /> SUBCONTRACTOR PHONE <br /> GUSCoNTRACToR Awass Crry1STA-E,2ZP <br /> �'lUcEMSE XC•Z 0 rel C D.ra .0 Other NUMBLR 425^4y E7.PtMAnON DATE 7131/.020 <br /> DCt>:EB71C W"L SAMPLINO:C GenertiI NlneraUColdorm Bacteria(,4381)G Dibromochlaropropane(4392)3 Arsenic(4393) <br /> 'INTENDEDLISE 0 DomestVRivate ❑Induzrt,eil C WatcrQualityMoniioring G SoiiSnmptwngChesctehaaon <br /> C Puot{c Water Systam <br /> If 0i(4 VnT ham Ov+wr. WG44r syNvT Nirni C�NAa.Nafa o'a:lcno Nun^Lar <br /> TY"00 WORK (NewWOH C Replacamant Well C Well t_ratwn/Medmwren 'u Otner <br /> C•Rionito iN wIl(a) V.-fwefls D Soil Borin6;s) C Gootechnical <br /> "A-O(-Scrvir Wcd :OuL.Oi•Sarvjce Well Renewed Cross-Connection nepalr <br /> G <br /> New Pump C PUMP Repiaoamant C Purne Repair c Raisc Well C cin <br /> WELL CONSTRUCTION <br /> �Dridlnp Method klud Rota Air Re-ary C Auger Cable Tool D Push Poin! C cmz, <br /> Proposed Well Depth c Excavation._. 20._in diameter D Opon Garan 14&r.vel P4,wGravrl Size -!319 in diamater <br /> CandUOtOr Coring n yiametu I Conductor Carina Depth It j <br /> Well Casing Clanteter�In ThluneaelGauge/ASTM Sated, .2.2 X S!%I ❑Plastic D Stair ass Sttd C Other <br /> Grout Seal Dapm 515 A D N-at Cemcnt(;S 1b=g'6-10 qat ve47 X Sand Cement /D. sau mrxn gal water <br /> G Bentonite(20%:olid6) C Cther i <br /> Grout Placement MettWd XPumo4&d C Free Fall Z OMer D neurdant'Aczc.tratur(name) I�PA� �� <br /> D sT D G D <br /> lnetailad By Driller (Pump Contractor = Cr Er rt TnY.St In ❑Cnr}aty Box G Stove Pipe �` 7 <br /> Concratc Pado:Lat COimanzionz:Width ft Lerra I _ IV♦ <br /> C,4�r: Subrner�i plaC Tutb'na ❑Other <br /> HP_ P:snP Sct P. Sl2ndtr19 WS!er Laver tt__ EJO <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WIT►f SAN I ���� <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED UCE <br /> CURRENT AND ACTIVE WITH THE CALIFORMA CONTRACTORS STATE LICENSE BOARD AND THAT I AAA IN COMPLIANCE WITH Oj{�U <br /> WORKERS C ENSATION S. N_ 13pN �t7jf��, <br /> M I d H U ADVANCE NOTICE REQUIRED P I. PFS� LEASE CALL(209)9 697 (���"e��1)11Ajr� <br /> SIGNED TIT.- DATE �� <br /> I I l i I <br /> Ii i f II I I <br /> I iI <br /> t I l N04TH <br /> I l II I I <br /> 506 <br /> CEIVED <br /> 26411 EpI <br /> iNRMIT(SERVICESS <br /> or�MENTAL HEALTH <br /> R F ENT U O L Y�nr. <br /> AppileaUon Accapted By D re � 0 ,drys`t� 3 Emp cyda IOa 1V11 <br /> Grout Inspecilon By- ~ Dste i0 L PECIAL VVoil Permit — <br /> Pump Inspy vn By Ds!a WAIVER Received <br /> Sal 8cring IncpeCier.By Dala Constructed Wap Depth Et <br /> COMMENTS <br /> PE SC Raae:ved Chadd' Amount Date a Permit! Invokc>`! WaiilDb <br /> Code In Ca:h Ramttcd rvicc u -ttt <br /> I+ _ V <br /> i <br /> I I <br /> ,�nceIved Tirre eN. 14. -2018— 7:52AM—No. 4137 <br /> �v•wf rertea cn aIu 'rJE!•L lPi]R7C PEfr <br /> RG <br />