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Site Address: 23020 Samra Hayer Ln, Acampo CA 95220 <br />Date: 9/2/2020 <br />PHOTO # 1 Well Loa. Grout seal set from 100 ft, <br />S) WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 EAST HA2ELTON AVENUE • STOCKTON CA 96206 -6262 (2D9) 488-420 <br />r NON-REFUNDABLE PERMIT www.sjgOV.org/eild <br />EXPIRES 1 YEAR FROM DATE ISSUED <br />JC Joe CROSS STREEDRESST <br />�� ) C� CITYfLP_ <br />C CROSS STREET_1 Tr-r�- APN r� / Qd J <br />-� t PARCELSIZE � LAND USE APPLICAno, 1f �7 <br />C OWNER NAME `y�� r% R, j//,(,/I/ PHONE � pQ 3rJ <br />OWNER ADDRESS A�� q CITYISTATEMP [� / <br />C CONTRACTOR /7 r�^.�r n �sE (Y�j J �PHONNEE /�33V- 7l- <br />C CONTRACTOR ADDRESS _ 000 /�yJ) C C 1 J7� CITYISTATPJZjP (�T��V-y�,���•••IP4'e <br />i SUBCONTRACTOR/CONSULTANT -&A2 %mAi 091.0 PHONE /TJ_ 2E2 <br />IC SUBCONTRACTORICONSULTANT ADDRESS r I CITYISTATdL�P <br />` LICENSE JK -57 0 C-61 0 D-09 0 OtherNuueER3 3 W ETPIRATON DATE_ -zs <br />BILLING PARTY: ❑OWNER O CONTRACTOR Q SUBCONTRACTORICONSIATANT <br />DOMESTIC WELL SAMPLING: kGeneral MineraVColiform Bacteria (4391) Pf Dlbromochloropropene (4392) D Arsenic (4393) <br />I1 INTENDED USE meslic/Private 0 Irrigation/Agricultural 0 Industrial 0 Water Quality Monitoring O Soil Sampling/Characterization <br />L 0 Public Water System <br />R ellrerexN nom 0—. Wafer Svsl—r Her- CMac1 Name a P— Nu <br />TYPE OF WORK _QgNew Well 0 Replacement Well 0 Well Afteration/Modlficelion 0 Other <br />O Monitoring Well(s) #ofwells O Soil Borings) 0l,a4as' 0 Geolechnkal edearwla° <br />D Out -Of -Service Well ❑ Out -Or -Service Wed Renewal 0 Cross -Connection Repair <br />ew Pum O Pu Re 1--nt ❑ Pum Re elr 0 Reiss Well Casino <br />WELL CONSTRUCTION <br />Drilling Method>WMud Rotary 0 Air Rotary 0 Auger O Cable Tool 0 Push Point ❑ Other_.. <br />Proposed Well Depth-�ft Excavation J'L-_.._ In diameter O Open Bodoni 0 Gravel Pack/Gravel Size in diameter <br />0 Conductor Casing in diameter 1 Conductor Casing Depth ft <br />_.{ C 0 Steel Plastic 0 Stainless Steel ❑ Other <br />Well Casing Diameler•� in TTlckness/Gauge/ASTM Sched7 -� and Cement %Q . � sack m&T al wetar <br />Grout Beal Depth %�� ft ONeat Cement (94 /b beg�10 gel water) / <br />S 0 <br />O Bentonite (20% solids) O Other 0 Relerdanll Accelerator (name) <br />Grout Placement Nlethod�umped ❑Ree Fall ❑ Other <br />PEDESTAL Installed By 81er 0 PUMP Contractor 0 OtherN fl Thick In ❑ Chrisry Bos O Stove Plpe <br />0 Concrete Pedestal ❑Dlmenslons: Width ft <br />"P Pump Set fl Stand ng Water Level fl <br />PUMP ubmersibleO Turbine O Other �. WILL BE DONE IN ACCORDANC IMT" 5 N <br />I HEREBY <br />COUNTY ORDINANCEtT:`ST'Al'E LAVVn' ANDTAUI-E9 �ANU TtEGUGA'ArSNBl T7.AG90 CE "r'r+AT kM REOU� <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE }WORK <br />•;�--JOAOUCURRENT AND ACTIVE VANWTr THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND AT I AM IN COMPL ANCE WITFt ALL - <br />wnRl(ERS COMPENSATION LAWS. _ cnn INSPFCTIONS - PLEASE CALL (209) 953-7697 _ <br />/S- 1-3 - Sit /Niq <br />2,7-,l I?-,ZX7 <br />. y9 7�i' •e�-i <br />/30-CAAe <br />ss— 0- sA,u/J <br />� 98- <-47 <br />Gee �.r <br />a2. L.�7 SQti2% <br />Z8r3-3._; rely <br />2 G•- 33P -%AAw <br />GtiR(rl <br />Record ID: WP0041146 <br />Francisco Garcia Ruiz, Environmental Health Asst. Page 1 of 3 <br />