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12,."14/2018 10:20 Canepa S Sons (FAX) P.004/006 <br /> ,' WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1888 EAST HAZELTON AVENUE-STOCKTON CA 85205-(209)468.9420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Joe ADeResa T2dj O Z dA¢/L J ,iGrrrLo Es e��^f GSA• 9S3 m <br /> CROS8 STRET To Med PRd. APN A07-1121D—.2 PARCIL StSlt/r/8 LANG USII APPLICATION# g <br /> OWNER NAME A Vim® / PHONE` p"Od/D A"e�C <br /> OWNERADDRESS RO/b 2 Pmkow Ad fL/ ITYISTATE21P kl$CP4_4PP,« <br /> � D / <br /> CONTRACTOR t�./yR/ t R &,QA dpy,, I k C. PHQNE J�i)S31 —117A <br /> CONTRACTOR ADDRESS /0.4;y at,&S)-.4 if <br /> f T• CrrYISTATE/ZIP � 7 <br /> SUBCONTRACTOR PHONIC <br /> SUBCONTRACTOR ADDiil CITYISTATQ21P <br /> LICENSE C•67 D Q-61 D•09 D 0th®r NUMBER EXPIRATION DATE?/—,V I <br /> DOMESTIC WELL.SAMPLING:u General Mineral/Coliform Bacteria(4391)C Dibromochloropropano(4392)❑Arsenic(4393) <br /> LUZEED�1sE Domestic/Private D Irrigation/Agricultural ID Industrial D Water Quality Monitoring D Soil SamplinglCharacterization <br /> D Public Water System P <br /> II dlkeent hom Ownw: ater yatem ams ontect Name or (tone Number Awr q Y <br /> TYCF OF WORK D New Well Replacement Well 0 Well Attention/Modlllcetlon 0 Other "� �tir <br /> it of borin a tot borinpe �� <br /> ❑Monitoring Well(s) #of wells 0 Soll Boring(s) 9 ❑ Geotechnical <br /> 0 Out-Of-Service Well D Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> Q New Pump U Pump Re lacoment J Pump Repair L' Raise Well Casing ,8 <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary C Air Rotary 7 Auger G Cable Tool G Push Point 0 Other qQ(J 8 <br /> Proposed Well Depth •O n Excavation i V•: In diameter 0 Open Bottom 0 Gravel Peck/Greve(Slze 8� In dlame T/RSH ryC0 <br /> D Conductor Casing In diameter I Conductor Owing Depth ft yOFpgRt 7,�h?), <br /> Well Casing Diamekrge d-hi augdSASTM hf:d a 5d Ateel ,i PlasllC u Stainless Steel Other <br /> Grout Seal Depth 6 1Q 0 New Cement(94 to begl5-10 gal water) 7 Sand Cement sack mlxl7 gal water <br /> VF Bentonite(20%solids) I Other <br /> Grout Placement Method Rkumped C Free Fall D Other C RetardantI Accelerator(name <br /> PJ09SYAL, Installed Sy 0 Driller APump Contractor 7 Other <br /> n Cancrotn Podoslal rtDlmanslons:Width it Length ftThick in I- Christ Box r•Stove PI e <br /> PUMD D Submersibles Turbine :Other HP Pump Set ft Standing Wator Level R <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. 1 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 /> WORKERS COMPENSATION LAWS. <br /> MI U 48 OUR ADVANCE NOTICE REQUIRED FOR SPECTIIONS-PLEASE CALL(209)953.7697 <br /> SICNGO Tl%e L1rSy4 AT 'DATE <br /> l <br /> Le <br /> i <br /> ^ I I <br /> i <br /> F�AA TMENT�7U 0 L <br /> Application Aaraptod By Date !/ Area Employee ID# <br /> Grout inspection By !n Date 0 PECIAL WeII Permit <br /> Pump Inapealon By f Date 0 WAIV@R Received <br /> Soil Boring Inspection ByCa�n/�tt d Wall D/gpth '�,n,r�t R <br /> COMMENTS � npl _ //�f z =,,,,5,_WKI�dfL— �k-- <br /> PE so Recolved Chack#/ Amount Date Permit/ Involce# Well ID# <br /> Code In ash emitted S rvloe Ra uvst# <br /> 2'i -1KHWi5i <br /> /l1LReceived Time—Dec. 14. -2018—'10 : 19AM—No, 4480 ��.y II11�'' 711-7� <br /> I-V Time-Dec, <br /> ,ti / A.t+•�, 9,5_711-72D <br /> s WELL(PUMP PERMR <br />