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WP0038857
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4200/4300 - Liquid Waste/Water Well Permits
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WP0038857
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Entry Properties
Last modified
11/28/2018 10:45:03 AM
Creation date
11/28/2018 9:37:48 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
WP0038857
PE
4381
STREET_NUMBER
27624
Direction
S
STREET_NAME
BANTA
STREET_TYPE
RD
City
TRACY
Zip
95304-
APN
25211012
ENTERED_DATE
10/4/2018 12:00:00 AM
SITE_LOCATION
27624 S BANTA RD
P_LOCATION
99
P_DISTRICT
005
QC Status
Approved
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EHD - Public
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W4 <br /> / 40 <br /> WELL/PUMP PERMIT I c <br /> SAN JOAQ UI4 COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABilE PERMITCALL 20 953-7 7 F R INSPECTIONS EXPIRES 1 AR FR I U D <br /> //,, CITY2IP G 49m <br /> JOB ADDRESS a <br /> CROSS STREET APN!r/�JL��1 O'ba—.�y✓�/P�ARCEL SIZE AND US PPLICGTION# <br /> OWNER NAME �/V�( /Yr✓ S P� PHONE -{ L"J LOQ ff <br /> /( rNo <br /> OWNER ADDRESS / ✓ a (CITY/STATE2IP V <br /> 14 <br /> CONTRACTOR ` <br /> aci 1Z <br /> PHHOONNEE �/ <br /> CONTRACTOR ADDRESS CITrT Y/STATE2IP <br /> SUBCONTRACTOR /yJ' _ _PHONE Aiffi <br /> SUBCONTRACTOR ADDRESS ITV/ST/ATTE21P �\r/ <br /> LICENSE C-57 C-61 D-09 Oth NUMBER ffi <br /> X tY 0 EXPIRATION DATE Z r6 _ <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> le <br /> INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells _ Soil Boring #of borings s) Geotechnical #of borings <br /> Out-Of-Service W OfOut-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump VPumpReplacement Pump Repair Raise Well Casino <br /> WELL CONSTRUCTION 1� <br /> Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point -I Other �►) <br /> Proposed Well Depth ft Excavation in diameter Open Bottom i Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad - Steel Plastic Stainless Steel Other Q, <br /> Grout Seal Depth ft Neat Cement(94 Ib bagl5-10 gal Water) Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal ,Dimensions:Width it Len th ft Thick in _.ChristyBox -iStove Pipe <br /> PUMP Submersible Turbine Other HP Pump Set-JO V It 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 ,�1 <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MI MUM 24 H{(7y�'R—ADVANCE NOTICE REQUIRED FORSPEC/T�IO/eNS-PLEASE CALL(209) 7697 .� <br /> SIGNED 11 [ r TITLE V Lll G DATE <br /> vV <br /> ri <br /> R qYM <br /> F�F�Vtir <br /> Cl o� Fp <br /> 11 L <br /> °qQ�, ?018 <br /> F q,QFN q���Y <br /> MFNr <br /> MENT US O L �h� <br /> Application Accepted By MVE�.' <br /> j I,3 ' Areas f--'—s— Employee ID#� / <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By �+ Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received hec I Amount Date PermlU Invoice# Well ID# <br /> Codes Info emitted Service Re uest# <br /> V <br /> EHD43-06 8/01!16 WELL/PUMP PERMIT <br />
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