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` AJ 4 c.w �� I� 3 /�� <br />t WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT/ <br />Sc <br />Info <br />CALL 209 953-7697 FOR INSPECTIONS <br />tArlrt C.7 i TLAM rMUIVI IVA1r 1100u Cu <br />JOB ADDRESS 3Q5 { <br />��^^ <br />�\ <br />ii ii <br />\2`•`f CITY/ZIP <br />C CL�n n 9 s 3u <br />�-1 <br />1, <br />A �� <br />-029(2-13 `A(AO&ND USE APPLICATION# <br />CROSS STREET tP1IR. %41"�% <br />42rl <br />-1141 <br />APN l 1 PARCEL SIZE <br />2 ZI <br />OWNER NAME ` <br />SIZOOTATI <br />PHON_El�ja.1 505 , <br />OWNER ADDRESS �� <br />V <br />a <br />` ��(� CITY/STATE/ZIP <br />� C'Or l�{I� Z� <br />CONTRACTOR �,�,Z�S <br />�i� <br />`��-_L�_r�� AMC -PHONE <br />+ <br />l'��7bb�� 7,,J_a! S l <br />�] <br />Pa / 3 LID <br />CONTRACTOR ADDRESS Li. <br />�/ <br />d CITYISTATE/ZIP <br />fA���� �Y` `S <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE /C-57 [] C-61 i] D-09 <br />PHONE <br />CITY/STATE/ZIP <br />❑ Other NUMBER 17 <br />(3 G2, EXPIRATION DATE <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br />INTENDED USE / Domestic/Private U Irrigation/Agricultural U Industrial E; Water Quality Monitoring U Soil Sampl <br />[) Public Water System <br />If different from Owner: Water System Name contact ame or Ph <br />TYPE OF WORK / New Well J/f Replacement Well ❑ Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings U Geotechnical #�f <br />❑ Out -Of -Service Well U Out -Of -Service Well Renewal ❑ Cross -Connection RepaiSAN IIA-..._ <br />New Pum r] Pum Replacement [IPum Re air F1Raise Well Casin E ^UuuV COUNTY <br />WELL CONSTRUCTION HEALTHJAL <br />Drilling Method /Mud Rotary r] Air Rotary L:, Auger U Cable Tool U Push Point 11 Other <br />NT <br />Proposed Well De th <br />p Depth -300 _ft Excavation - i I A_ in diameter ❑Open Bottom / Gravel Pack/Gravel Size _�,�_ in diameter <br />U Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter 6 in Thickness/Gauge/ASTM SchedZAL J Steel �dPlastic L] Stainless Steel ❑ Other <br />Grout Seal Depth ; Neat Cement (94 Ib bag/5-10 gal water) Sand Cement O. '71t sack mix/7 gal water <br />I:-1 Bentonite (20% solids) [ ] Other Z X11+15 112=d ftf -k C_AA_1 ...jC <br />Grout Placement Method Pumped D Free Fall [, Other [1 Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller _; Pump Contractor X Other <br />Concrete Pedestal CDimensions: Width ft Length _ ft Thick in ❑ Christy Box ❑ Stove Pine <br />PUMP [ Submersible[) Turbine ❑ Other HP Pump Set ft Standing Water Level ft <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 COMPENSATION LAWS. <br />MINIMUM 24 HOUR A ANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 1 <br />SIGNED C TITLE y .. DATE �� V / �T <br />- t EPL <br />TM <br />ENT YSE <br />/ ION LY <br />Application Accepted Date 2' Z S / <br />Grout Inspection By Date 3 <br />Pump Inspection B Date <br />Soil Boring Inspection By <br />COMNjS <br />Date <br />Area Employee IDimkrb <br />❑ SPE ' <br />IAL WCII Permit <br />WAIVER Received <br />Constructed Well <br />ft <br />PE <br />Codes <br />Sc <br />Info <br />Received <br />B <br />heck <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # <br />Well ID# <br />42rl <br />-1141 <br />0 <br />2 ZI <br />l t-7 <br />SIZOOTATI <br />W rQ0 3 rb331 <br />4m( <br />-OL: <br />LM <br />EHD 43.06 <br />4130/12 WELL /PUMP PERMIT <br />