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12/21/2013 10;17Canepa S Sons (FAX) P.002/004 <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNT`/ENVIRONMENTAL HEALTH DEPARTMENT 1865 EAST HAZELTON AVENUC-STOCKYON CA 95205-(209)488.3420 <br /> NON-REFUNDABLE PERMIT CALL 2 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FRO DATE ISSUED <br /> m <br /> Joe ADDRE86 I AID CI1Yl21p r� <br /> • D <br /> CROSSSTRI78T APN (rJ.���-lla PARCEL 9Q �UEI?APPITION# <br /> OWNER NAM9 •4 I PHo F <br /> OWNER ADDRESS CirrylVAYOZIP <br /> CONTRACTOR PHON <br /> CONTRACTOR ADDRESS CITY/STAT@fZI <br /> SUBCONTRAC70R PHONE! <br /> SUBCONTRACTOR ADDRE83 CI /SYATEIZIP <br /> LICENSE C-57 0 C-61 C D-09 ❑Other Numau EXPIRATION DATE Zo o <br /> V. <br /> DOMESTIC WELL SAMPLING;D General Mineral/Collform Bacteria(4391)r„Dibromochloropropane(4392)0 Arsenic(4$93) <br /> INTENDED USE YDomestic/Prlvete 0 IrrlgatlonlAgriculturel 0 Industrial 0 Water Quality Monitoring p Soil Sampling/Cherecierization <br /> 0 PubllC Water System <br /> If different kam Owner Walar syatam Nam, Cattiest Nam!or Phone Numtoer <br /> TYPE OF WORK C New Well 7 Replacement Well 0 Wall Alteration/Modification D Other <br /> G Monitoring Well(s) to of welts O Soll Soring(s) a of Gann' 0 GcoteChnICAI a vl bvrine. <br /> 0 Out-Of-Sorvico Well 0 Out-Of-Service Well Renewal C Cross-Connection Repair <br /> D New Pump 0 Pump Replacement )(Purnp Repair r Raise Wc11 Casing <br /> WELL CONSTRUCTION / �.-viwa4r> "" <br /> Drilling Method C Mud Rotary C Air Rotary 7 Auger` ❑Cable Tool C IPush Point 1f other A <br /> Proposed Well Depth k Excavation in diameter D Open Bottom o Gravel PacWGravel Size in diameter A k <br /> 0 Conductor Casing In diameter / Conductor Casing Depth ft <br /> Well Casing ClemeterIn Thlcknesa/Oeuge/ASTM Sched J Steel _PlasOc u Stainless Steel u Other �+r �►A <br /> Grout Seal Depth fl:R 0 Neat Cement(94 lb bag/5-10 gel water) Send Cement sack mixl7 gal wale /e eo <br /> i Bentonlle(20916colds) I Other L 9 <br /> Grout Placement Method 0 Pumpcd C Frcc Fall I: rd <br /> Other C Retardant/Accelerator name 'AIqQV `018 <br /> PEDE5YAL Installed By 7 Driller D Pump Conlracl�r J Other �H (! <br /> CQ(� <br /> n Concrete Pedestal rlDlrnenslons'Width ft Length R Thick in r-Christy BOX C Stove Pip �rVj(' <br /> QIPFHT�AIn, <br /> PUMD 0 Submorsiblo Turbine J Other. HP Pump Set IN Standing Wotor Level ft RT,y <br /> 1 HERESY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN FHT <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS, I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT A CTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS ENSATION <br /> 8 VANCE NOTICE REQUIRED FORMNISf ljCTIIIDITS-P EASE CALL(209)959.7 97 <br /> SIGNED Trri.e DATE <br /> I 1 <br /> Ilk <br /> i <br /> i <br /> P-4MENT U E 0 Y <br /> Application Accepted By to Area Employee 10# <br /> Grout Inspection By Date�1 _ 0 PEaAL Well Permit <br /> Pump Inspection By Del-!_f zl.t ids 0 WAIvER Received <br /> 5oll Boring Inspection By Date Constructed Well Depth It <br /> COMMENTS <br /> PE Sc Received ChaCkill Amount bate Permit/ Invoice# well 10# <br /> Codea Into asfi Ramittod ServlceRe uest# <br /> —Received Time—Dec. 21, -2018-10, 16Ak—No, 4507 <br /> I ' &C 41-0e n 6*a!4114/18 g,l/S 77 N'OIUPUIdD PERMIT <br />