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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 . (209) 468-3420 <br />NON-REFUNDABLE P➢YMIT CALL (209) 953-7tI97 FOR INSPESTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />Joe ADDRESS j VL J 1 - CITYIMPP %/�!/�Lt,! I — / LX—•'J"L/ <br />CROSS STREE Y ! APN //1q0O// ARCEL SIZE rL�/IOLAND USE/ APPLICATION # <br />WNER NAME 17 J/ fir f�A1, "/ <br />WNER ADDRESS�O �� / <br />ONTRACTOR CANEPA AND SONS, INC. <br />ONTRACTOR ADDRESS 14384 CUESTA COURT <br />PHONE <br />CrrY/STATEIZIP <br />PHONE (209)532-1136 <br />CITY/STATEMP SONORA, CA 95370 <br />PHONE <br />SUBCONTRACTOR ADDRESS CrTY/STATEZP <br />LICENSE CXC-57 D C-61 ❑ 0-09 ❑ Other NUMBER 425749 E%PIRATION DATE 7/31/2020 <br />DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) 0 Dibromochloropropane (4392) ❑ Arsenic (4393) <br />NTENDED USE 0 DomesticJPrivate rrigation/Agricultural C Industrial D Water Quality Monitoring ❑ Soil Sampling/Characterization <br />❑ Public Water System <br />If different from Owner. Water System Name Contact Name or Phone Number <br />rYPE OF WORK YNew Well O Replacement Well 0 Well Alteration/Modification O Other <br />0 Monitoring Well(s) *of wells ❑ Soil Boring(s) o of oonngs ❑ Geotechnical i O10o—gs <br />0 Out -Of -Service WeII C Out -Of -Service Well Renewal D Cross -Connection Repair <br />❑ New Pumo 0 Pumo Replacement 0 Pumo Reoair ❑ Raise Well Casino <br />Drilling Method'fvlud Rotary ❑ Air Rotary 0 Auger n Cable Tool ❑ Push Point ❑ Other <br />Proposed Well DepthII�M_It Excavation _2 6, in diameter 0 Open Bottom ,Gravel Pack/Gravel Size in dia <br />Conductor Casing 30 in diameter / Conductor Casing Depth ft H�w <br />Well Casing Diameter _& in Thickness/Gauge/ASTM Silted ZSb Steel C Plastic C Stainless Steel D Other <br />Grout Seal Depth 9b It D Neat Cement (94 Ib bag/5-10 gal water) (Sand Cement 10.3SK sack m1x/7 gal water <br />❑ Bentonite (20% solids) C Other <br />Grout Placement Method Pumped ❑ Free Fall D Other O Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller Pump Contractor Fl Other EIConcrete Pedestal ❑Dimensions: Width ft Length It Thick in C Christy Box 0 Stove Pipe <br />PUMP G SubmersibleO Turbine 0 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 AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />PA y4'E�vr <br />` 6- <br />n <br />,/0 11 2018 <br />fO)i, <br />ryN��U <br />ry oP�MN <br />E P T M E N T U /E N Y <br />Application Accepted By /.. Date • / AreaEmployee ID#� <br />Grout Inspection By Date ❑Well Permit <br />Pump Inspection By Date C WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />�. ■ !J E*3 w <br />EMD 4J-06 ra -d 411411E Q� / pWELL/PUMP PERMIT <br />