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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 EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS d I dL Ve. LL G r7r <br /> �j <br /> CROSS STREET L /�1`79S � APN 2—'Y 7—1-30 <br /> —ZCEL SIZE I QLAND USE APPLCAnON¢ D <br /> _ a�� nl,ek H <br /> OWNER NAME �J ✓D t PHONE 4�-�0/0 <br /> OWNER ADDRESS .7,0102. h U h /"T L CITY/STATEILE <br /> P –C—/"('L i o n q-5;3Z? <br /> CONTRACTOR CANEPA AND SONS,INC. PHONE (209)532-1136 <br /> CONTRACTOR ADDRESS 14384 CUESTA COURT CITY/STATE/ZIP SONORA,CA 95370 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/LP <br /> LICENSE LXC-57 D C-61 ❑D-09 ❑Other NUMBER 425749 EXPIRATION DATE 7/31/2020 <br /> DoMESnC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)D Dibromochloropropane(4392)0 Arsenic(4393) <br /> INTENDED USE )<Domestir/Private ❑Irrigation/Agricultural D Industrial ❑Water Quality Monitoring D Soil Sampling/Characterizabon <br /> D Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK D New Well XReplacement Well D Well Alteration/Modification D Other <br /> ❑Monitoring Well(s) #of wells ❑Soil Bodng(s) #of borings D Geotechnical #of borings <br /> ❑Out-Of-Service Well D Out-Of-Service Well Renewal D Cross-Connection Repair <br /> ❑New Pump ❑Pump Replacement D Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method'Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool C Push Point ❑ Other <br /> Proposed Well Depth 300 it Excavation S r< in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter�in Thickness/Gauge/ASTM Schad r 50 Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth ft ❑Neat Cement(94 Ib bag/5-10 gal water) ❑Sand Cement sack mixll gal water <br /> XBentonite(20%solids) ❑Other <br /> Grout Placement Method YPumped D Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller XPump Contractor ❑ Other <br /> ❑Concrete Pedestal❑Dimensions:Width ft Length ft Thick in D Christy Box ❑Stove Pipe <br /> PUMP ❑Submersible❑Turbine ❑Other HP Pump Set ft Standing Water Level ft <br /> 1 HEREBY CERTIFY THAT 1 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 /> WORKERS CO,MP'ENSATION LAWS. <br /> 17114M�38 H ADVANCE NOTICE REQUIRED 0 IN.PECTIO S-P EASE CALL(209)953g9A� <br /> SIGNED TITLE DATE r• 9' <br /> } <br /> i r ' <br /> I ! <br /> i <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Area Employee ID# <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC I Received Cher <br /> k#/ Amount Date Permit/ Invoice# WeII1D# <br /> Codes Into 8 Cash Remitted Service Re uest# <br /> EHO 43-06 revised 4/14113 WELL/PUMP PERMIT <br />