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SR0075864
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4200/4300 - Liquid Waste/Water Well Permits
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SR0075864
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Entry Properties
Last modified
6/27/2018 2:15:33 PM
Creation date
6/25/2018 3:03:20 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
SR0075864
PE
4378
FACILITY_NAME
RICHARD MENDOZA
STREET_NUMBER
24711
Direction
S
STREET_NAME
CHRISMAN
STREET_TYPE
RD
City
TRACY
Zip
95304
APN
25016012
ENTERED_DATE
6/25/2018
SITE_LOCATION
24711 S CHRISMAN RD
RECEIVED_DATE
9/23/2016
P_LOCATION
99
P_DISTRICT
005
Tags
EHD - Public
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Son <br />WELUPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT GALL (ZU9) 5b3 -/by/ FOR INSPECTIONS r-ArrrsIC-a I Tr -API rrlvm vHIM wouau <br />JOB ADDRESS�/�� CITY21P <br />CROSS STREET C 4 j'r ig_ APN 9, SO I (eQ I 2 --PARCEL SIZE LAND USE APPLICATION # <br />OWNER NAME P, C-4 &4 RLI0 A ijALj 2I PHONE -3 `16 - 0 22 f <br />OWNS i ADDRESS �A / CITY/STATE/ZIP <br />CONTRACTOR J (::4 /- l W.� �i��r dr7 /Q. � �r Q CG . L PHONE 7Ls j-'- G��Z (Gr <br />CONTRACTOR ADDRESS _ ,f:$ . A: CITY/STATE/ZIP Lelap k C4.!q a xa <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br />LICENSE !I -G-57 ' I C-61 I D-09 11 Other NUMBER %J44,2- EXPIRATION DATE J /,7 <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br />NTENDED USE ii�omestic/Private 1-:Irrigation/Agricultural U Industrial ❑ Water Quality Monitoring U Soil Sampling/Characterization <br />[I Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK New Well ReDiacement Well fl Well Alteratinn/Morlifiratinn n nthar <br />U Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings 1' Geotechnical # of borings <br />❑ Out -Of -Service Well 11 Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />I I New Pum F' Pump Replacement ❑ Pump Repair t7 Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method "ud Rotary ❑ Air Rotary i-, Auger LlCable Tool ❑ Push Point F1Other <br />/ <br />Proposed Well Depth�IA qmExcavation & in diameter ❑ Open Bottom 0-�5_ravel Pack/Gravel Size _ in diameter <br />❑ Conductor Casing in diameter / Conductor CasingDepth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched I �1/Steel ` mftstic C Stainless Steel ❑ Other <br />Grout Seal Depth �,� 0 l Neat Cement (94 Ib bag/5-10 gal water) r""' Sand Cement _ sack mix/7 gal water <br />^—' `-- �"`"`4-11entonite (20% solids) ! 1 Other <br />(�%:L f — <br />Grout Placement Method ,i�umped r_� Free Fall C Other 13 Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ump Contractor ❑ Other <br />1, Concrete Pedestal F. Dimensions: Width ft Length ft Thick in 1 Christy Box n Stove Pipe <br />PUMP j%30bmersibleO Turbine I; 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 REOUIRED LICENSE IS <br />CURRENT D ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS OMPENSATION LAWS. <br />M IMU 124k. ADVANCE NOTICE REQUIRED FOR INSPECTI NS - PLEASE CALL (209) 953-7697 <br />SIGNED TITLE �1,'1 I / �ss DATE Z% " % '" /6 <br />[n <br />m <br />D <br />0 <br />M <br />n <br />m <br />N <br />c Drf'ARTMENr l3 <br />i T�+ EN QUIN COUVTy <br />Application Accepted By Date (�_ Area EN7��AeI)a44 <br />Grout Inspection By Date v ElSPECIAL Weil PerMlt <br />Pump Inspection By Date ❑ WAIVER Received <br />Soil Boring Inspection By _ Date Constructed Well Depth ft <br />COMMENTS .,.>I �! Lti t-- 4 -�S a,-1_ <br />5 �.b ; � " �►l arm � w1.; u - :-'.o� Cpf,� <br />PE <br />Codes <br />SC <br />Info <br />Received <br />B <br />Chec <br />Cash <br />Amount Dace <br />Remitted <br />Permit/ <br />Serv's:�^ Request # <br />Invoice # <br />Well ID# <br />4-V72-11 <br />34 ! '� <br />q 12,3 tj(o <br />&120075g(Qy <br />1 <br />912,;b/10Sa-00-150 <br />EHD 43-06 WELL/PUMP PERMIT <br />4/30/12 <br />
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