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12/14/2018 10: 20 Canepa & Sons (FAX) <br />• <br />I <br />WELL/PUMP PERMIT <br />SAN JOAOUIN COuNTY ENVIRONMCNYAL (HEALTH DEPARTMENT 1868 EAST HASELTON AVENUE - STOCKTON CA 95205 - (209) 488.3420 <br />Joa ADDRESS Ail 7z--5 "-4 04)4. 4d.'I CrTY2Nw_ <br />tP e_4P,6 , CA • <br />CRO88 STREET 04H 41^1 ye l,, APN 04yH- /gyp + 2) PARCEL SIZE lI� LAND UBE APPLICATION 11 <br />OWNER NAME QR1 AAW II,, I L, 0AJ M PHONE1a7'f2 / TI001 A" 'Vel <br />OWNER ADDRESS ado/off.. �Ar/ 4,0' CITY/5TATCIZIP ,&gAe.0A, CA- 933�a <br />r <br />CONrP=Y0R (_ IING a f_ `Y ` �DAl PHON@S/�3,r�'�-�// <br />CONYRAcTORADDRESS 0� 0S7 C!/G.STI� - CITYISTAT10P 4ONO�W <br />� - 9-S;:7>,d <br />SUBCONTRACTOR <br />PHONE <br />SUBCONTRACTOR ADDRESS I, CITYISTATE/ZZIIP <br />LICENSE YC -57 D 0-61 C D-09 7 Other Numaak''�s 7 7 EXPIRATION DATE 7 <br />DOMESTIC WELL SAMPLING: 0 General Mineral/Coliform Bacteria (4391) G Dibromochloropropane (4392) 0 Arsenic (4393) <br />INTeNDab UseDlDomw1clPfIVate 0 Irrigation/Agricultural ;D Industrial D Water Quallly Monitoring 0 $0 Sampling/Characterization <br />U Public Water System ' <br />If 6ffe om From 0-6': WPlar.-yeti. Nama Conlaet Nemo or Phone Number <br />TY►8 Or WQitr( New Well Replacement Well 0 Well Alteration/Modification 0 Other <br />u Monilcring Well(a) aor wells D Soil Boeiril 8crboOgs 0 GeoieehrIcal i+al bortnge 1 <br />G Out -Of Sarvlce Well U Out -Of -Service Well Renewal in Cross -Connection Repair <br />N <br />"v <br />Drilling Method A Mud Rotary C Air Rotary D Auger 0 Cable Tool C Push Point C Other I <br />Proposed Well Deh ptOb H Excavation � In diameter ] Open Bottom )(Gravel Pack/Gravel Slze a In diameter <br />D Conductor Casing In dlameter /! Conductor Casing Deplh ft <br />Well Casing Diameter Thickness/Gauge/ASTM Schad . ZS -a (Steel J Plastic u Stainless Sleet U Other <br />Grout Seal Depth ft D Neal Cement (94 /D beg/5-10 gal water) 7 Send Cement sack m1x17 gal water <br />i�Bent nils (" solids) Othor <br />Grout Placement Methotl I Pum ed C Free Fall 0 Other C Retardant / Accelerator name <br />EBQESIB6 Installed By C Driller 21 Pump Convector 7 Other <br />n Concrete Podostal r1Dlm9nslons: Width h Length ft Thick In r- Christy Box r- Stow Pipe <br />I 0 Submersible Turbine _ Other HP Pum Se ft Standing Water Levet ft <br />I 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 REQULATIONB. I ALSO CERTIFY THAT MY�REQUIRED LICENSE 18 <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS C MPENSATION LAWS, I <br />ICE REQUIRED FO NSPECTIONS - PLEASE CALL (209) 953 7697 J <br />SIGNEDM MU 3 TITLE 4/'y_F/V 7-- DATE <br />P,002/OOE <br />YMENT <br />Application Accepted By <br />PA TMENT USE ON Y <br />ateAIL <br />Area Employee ID#A"rw <br />Grout Inspection By <br />H t Date <br />O Wall Permit <br />Pump Inspection By <br />Date <br />0 WAIVER Received <br />Soil Boring Ins action By <br />Date <br />Constructed ell Depth <br />�_ C-� (-b P <br />ft <br />—) �L- <br />COMMENTS j2gj <br />I <br />. C <br />. <br />��Perrin <br />- --- -- <br />4Lt n„ , <br />Received i Imes ec"7- <br />7q�cn� T e <br />WfyU, /PUMP MIRKY <br />