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Site Address: 3125 Orange St, Acampo CA 95220 Record ID: WP0041668 <br /> Date: 4/5/2021 <br /> PHOTO# 1 New Well.Well Lo . Grouted with 10.3 sand cement from 200 ft. <br /> �r <br /> WELUPUMP PERMIT <br /> ANtiQ.000IN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 11168 EAST HAZELTON AVENUE-STOCKTON A95205-6232(2091466-]420 <br /> NON-REFUNDABLE PERMIT2�`2 <br /> ,W�WW�.S OV.OF /ehd <br /> EPRE�S 1�YEAR FROM <br /> DATE ISSUED <br /> J�A <br /> JOBADDRESS <br /> CROSS STREET CrrYZP � <br /> OWER NAME APIN 1PARCEL SIZENAN.USE APPLICATION IN <br /> ` I AI— <br /> OWNER ADDRESS rCITY/STATE/ZIP PHONE e/ <br /> CONTRACTOR t <br /> //�1-��/1✓/(/�/"/��// <br /> � <br /> ] <br /> / 'T <br /> /J PHONE / <br /> CONTRACTOR ADDRESS I.JtIf 0 <br /> CITY/$TATFl21P Ail[/ r� <br /> SUBCONTRACTOR/CONSULTAWT,e,-., rA 1540--.S ryTn Z< �,G <br /> PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS <br /> CIN/STATE/ZIP <br /> LICENSE -QC-57 O C-61 ❑D-09 fl Other 'OlSf4(7 <br /> �A�_ NUMBER EXPIRATION DATE v v <br /> BILLING PARTY; ❑vWNER ❑CONTRACTOR C1 SUBCONTRACTOR/CONSULTANT <br /> DOMEsnc WELL SAMPUNC.;D General Mineral/Coliform Bacteria(4391)0 Dibromochioropfopane(4392),^,Arsenic(4393) <br /> INTENDED USE -I­'YDomesflc/Prfvate O IngatiordApucultural U Industrial O Water Quality Monitoring ❑Soil Sampling/Characledzallon <br /> ❑Public Water System <br /> V dklereni f,nm Ovmer Water System Nine GOMgI Name a parva Hamper -7 <br /> TYPE OF WORK WN—Well epiacement Well O Well Atteration/ModificaliOn ❑Other r Z <br /> ❑Monitoring Well(s) #of wells D Soil Borings) NO("' U Geotechnical pl, <br /> OOut-Of-Service Well ❑Out-Of-Service Well Renewal D Cross-Connection Repair ,v�� "� f �3�� V�I✓` <br /> ew Pum <br /> WELL CONSTRUCTION ❑Pump Replacement ❑Pump Repair O Raise Well CaSi2g A <br /> Drilling Method 4eMud Rotary O Air Rotary D AugerU Cable Tool 13Push Point Other �OAQUIN CO �"�/ L/�-7 G <br /> Proposed Well Depth 9'0-0 /`J <br /> tt Excavation�in diameter D Open Bottom 0 Gravel PBdUGravel SIz Ty{DE p"�T/q�@� 7 ,( <br /> ❑Conductor Casing in diameter / Conductor�Casing Depth_fl ---P� ""`^r7"ler Z7S�S' <br /> Well Casing Diameter F_in Thickness/Gauge/ASTM Sched� ❑Steel <j Plastic U Stainle��stt^feel ❑Other— <br /> 0 <br /> Grout Seal DeptfrL 2710 R O Neat Cement(94/b bagr5-10 get wafer) -4;L-Sand Cement V, / (J <br /> sack mrxf7 gal water <br /> ❑Bentonite(20%solos) ❑Other <br /> Grout Placement Method ❑Pumped O Free Fail O Other ❑Retardant/Accelerator(name) - '� j <br /> PEDESTAL In-tailed By A3�Dnller O Pump Contractor/, (!,1Olher <br /> 0 Concrete Pedestal ODlmenslDns Width N Len In R Thick I n rH "7 =; <br /> 9 —r-- Stove rlPe '16'-J Z V V" �LJ <br /> PUMP SubmersibleD Turbine D Other. HP Pump Sel R Standing Water Levell— ft <br /> 1 EBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE.WORK WILL BE DONE IN ACCORDANCE_VYIAi„S,pN.,,,; <br /> -,D7CQU(N 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 COMPENSATION LAWS. <br /> Ml/ :cK448 HQ�UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE f (V/� IL <br /> DATE Z <br /> Hd <br /> 0 <br /> Francisco Garcia Ruiz, Environmental Health Asst. Page 1 of 2 <br />