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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY EWIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE • STOCKTON CA 95205 - (209) 468- <br />NON-REFUNDABLP PPOUIT CALL0912 ) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISS <br />JOB ADDRESS f � _ CITY/LP <br />1 <br />CROSS STREET �I G�7 /C'/ 7 / '• `^ CAI�N�Z�L'a^� �I �ARCEL SIZE LAND U APPLICATION it <br />OWNER NAME _-/�/ I�f��^� 1 1\ 1 11 -TY �I -�T'VI I CU 1� /yPHHOON�gsl�-7i4v -�1- 2s <br />OWNER ADORESS 7C ' =`K JVO�S CITY/STATEILPVI +C� A410I( Gsc)-1 <br />CONTRACTOR CANEPA AND SONS, INC PHONE (209) 532-1176 <br />CONTRACTOR ADDRESS 1.3784 CUESTA COURT CITY/STATE/ZJP SONORA, CA 95370 <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS CITY/STATEZP <br />LICENSE IXLC-57 C C-61 D-09 G Othef NUMBER 425749 E%PIRATION DATE 73 1.2020 <br />DOMESTIC WELL SAMPLING: 0 General Mireral/Coliform Bacteria (4391) Dibromochloropropane (4392) U Arsenic (4393) <br />INTENDED USE '•i DomestmfPrivate C Irrigation/Agricultural Alridustrial C Water Duality Monitoring - Sod Samphng/CharactenzauDn <br />Public Water System <br />If d,1—nit from Owner: Water System Name Ccntect Name or stone NJmbe. <br />TYPE OF WORK XjNew Well = Replacement Well Well AlteraLorvtilodihcabon _i utner <br />C Monitoring Well(s) # of wells =: Sod Bonng(s) a cf bann9s -, Geotechnical <br />C Out -Of -Service `Nell - Cut -Of -Service Well Renewal Cross -Connection Repair <br />New Pumc L Pump Replacemert = Pump Repair Rase Well Casing _ <br />Drilling Method Rotary <br />r''�. � Air Rotary _ Auger -i Cable Tool _ Push Point Other I <br />Proposed Well Depth �%yQ Y, Excavation 2Ci �n diameter Open Bottom Gravel PaGdGravel <br />Size <br />in dna <br />XConduclor Casing Z -Y In diameter 1 Conductor Casing Depth It <br />Well Casing Diameter in Th ckress/Gauge;ASTM S&ed AZ SC)X Steel :J Plastic ,Stainless Steel - O:her <br />Grout Seal Depth DO It = Neat Cement !9416 bag/5-TO ga era;er; Sand Cement Sack mrx/7 gal v ate <br />XBeritonite (20% solids) Other <br />Grout Placement Method Pumped Free Fall - Oro- 'i Retardant / Accelerator (name) <br />PEDESTAL Installed By L Drille• Pump Contractor - Other <br />G Concrete Pedestal -Dimensions: %MdM tt Length R Thick in Christy Box C Stove Pipe I <br />PUMP C_ Submersible_ Turbine 7 Other HP Pump Sc: 1 Standing Water Level K <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAOUIN 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 1 AM IN COMPLIANCE WITH ALL <br />WORKERS CPAP NSATION LAW <br />P7) I '.�/�J�HHO,U. AAD! E NOTICE REQUIRED F 1R/ t SPEC jti./l^OyJ�fGSy-�PLLJ[EASE CALL (209) 95I3-7697 �n <br />SIGNED / V �V TITLE ' �S `� - `� r DATE <br />1 1 1 1 1 1 1 1 1 1 1 1 1 ISI l l l l l l I i l l I- <br />E LR M E N T U E O L <br />Application Accepted By Date Area Employee 10# <br />Grout Inspection By DateWell Permit <br />Pump Inspection By _ Date '7 WAIVER Received _ <br />Sod Boring Inspection By - Date Constructed Well Depth <br />FA- <br />-15 <br />,yJ►l�r.�.�J�� - .:STJG1{C��li►:rT�`�lri� -_ <br />ENO 4:-C: 1—d 4l•-1110 <br />WE_L,-PUVP PEPMr <br />RF Y�ERr <br />kA / v CF�V�D <br />V J l y ?019 <br />, "QW CO <br />CT r�FpMR�Tq�N)Y <br />MFNT <br />