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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 PERMITCALL 209 953-7697 FOR INSPECTION EXPIRES 1 YEAR FROM DATE ISSUED <br /> �7 ( S to <br /> JOB ADDRESS I yp� 7—;_ ` wo CITY/ZIP �+ In <br /> �J D <br /> CROSS STREET d/� � APN 101-13D.{1/`mJ� PARCEL SIZE`� LAND US PPUCA nON# <br /> A <br /> 20 _Mao m <br /> OWNER NAME PHONE y� !i <br /> OWNER ADDRESS CITYISTATE/Z1P ,` <br /> CONTRACTOR CANEPA AND SONS,INC. PHONE (209)532-1136 <br /> CONTRACTOR ADDRESS 14384 CUESTA COURT CITY/STATE/LP SONORA,CA 95370 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATEMP <br /> LICENSE ICC-57 ❑C-61 ❑0-09 D Other NUMBER 425749 EXPIRATION DATE 7/31/2020 <br /> DOMESTIC WELL SAMPLING:0 General Mineral/Coliform Bacteria(4391)0 Dibromochloropropane(4392)D Arsenic(4393) <br /> INTENDED USE omesticlPrivate ❑Irrigation/Agricultural 0 Industrial 0 Water Quality Monitoring 0 Soil Sampling/Characterization <br /> 0 Public Water System <br /> It different from Owner. Water System Name Contact Name or Phone Number <br /> TYPE OF WORKew Well ❑Replacement Well 0 Well Alteration/Modification 0 Other <br /> IKV 0 Monitoring Well(s) #of wells 0 Soil Boring(s) a or bo ngs 0 Geotechnical #of borings <br /> ❑Out-Of-Service Well 0 Out-Of-Service Well Renewal D Cross-Connection Repair <br /> 0 New Pump ❑Pump Replacement 0 Pump Repair 0 Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary ❑Air Rotary 0 Auger 0 Cable Tool 0 Push Point ❑ Other <br /> Proposed Well Depth 300 ft Excavation 1'2-_in diameter 0 Open Bottom Gravel Pack/Gravel Size in diameter <br /> 0 Conductor Casing in diameter / Conductor C sing Depth ft <br /> Well Casing Diameter_10 in Thickness/Gauge/ASTM Sched 0 Steel *Iastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth )t)0 ft 0 Neat Cement(94 to bag/5-10 gal water) 0 Sand Cement sack mixrl gal water <br /> Bentonite(20%solids) ❑Other <br /> Grout Placement Method y1pumped 0 Free Fall 0 Other 0 Retardant/Accelerator(name) <br /> PEDESTAL Installed By 0 Driller 0 Pump Contractor 0 Other <br /> 0 Concrete Pedestal ODimensions:Width ft Length ft Thick in 0 Christy Box 0 Stove Pipe <br /> PUMP ❑Submersible Turbine 0 Other HP Pump Set ft Standing Water Level It <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 /> WORKERS COMP NSATION LAW .'. <br /> M1 I IVB 4 HOU A VANCE NOTICE REQUIRED F I SPEQTI NS-PLEASE CALL(209)953-7697 <br /> SIGNED C / ��'� d i` � TITLE DATE <br /> d <br /> PAYMENT <br /> RECEIVED <br /> IT <br /> YJN <br /> r v 19 2019 <br /> / I SAN JOAQUIN COUNTY, <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> 77 t t <br /> PRTMENT U O LY <br /> Application Accepted By Date ( Area Employee ID#( <br /> Grout Inspection By ❑ PECIAL Well Permit <br /> Pump Inspection ate ❑ WAIVER Received <br /> Soil Boring I pe ')n By Date Constructed Well De th ft <br /> OMME TS d <br /> - r ! :' ' <br /> PE SC Received Check#I A ount Pe it/ <br /> codes I fO B Cash mi ed Date S ice Request# Invoice# Well ID# <br /> sI AA'00 <br /> :1621 S <br /> $ o j�� <br /> ` rot � <br /> WELL/PUMP PERMR t/V 1 OO <br /> - • �� <br /> r EHD 43-06 revised 4/14/19 "---1 �J' <br />