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WP0039175
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4200/4300 - Liquid Waste/Water Well Permits
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WP0039175
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Entry Properties
Last modified
3/25/2019 9:39:23 AM
Creation date
3/25/2019 9:34:02 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
WP0039175
PE
4381
STREET_NUMBER
998
Direction
W
STREET_NAME
MATHEWS
STREET_TYPE
RD
City
FRENCH CAMP
Zip
95231-
APN
19318061
ENTERED_DATE
1/8/2019 12:00:00 AM
SITE_LOCATION
998 W MATHEWS RD
P_LOCATION
99
P_DISTRICT
001
QC Status
Approved
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EHD - Public
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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL.HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS CITY/ZIP rom m <br /> /] I T n <br /> CROSS STREET ne`Rc�c�l APN M C _PARCEL SIZE LAND USE APPLICATION# <br /> OWNER NAME ' PHONE �(J`�/ <br /> OWNER ADDRESS CITY/STATE/ZIP t'C Lh elil�C- �V3l <br /> qRt z�yg �- <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS �) CITY/STATE/ZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP J� <br /> LICENSE C-57 ❑ C-61 ❑ D-09 El Other NUMBER EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE (Domestic/Private ❑ Irrigation/Agricultural =i Industrial I I 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 I I Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> ❑ New Pump )(Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool I i Push Point ❑ Other <br /> Proposed Well Depth ft Excavation in diameter ❑ Open Bottom Ll Gravel Pack/Gravel Size in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched rI Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth ft ❑ Neat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other i 1 Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller 1.1 Pump Contractor ❑ Other <br /> Concrete Pedestal Li Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP Submersible[] Turbine ❑ Other HP 0 11 Pump Set ft Standing Water Level ft <br /> 1 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 /> M=1 =ADVANCE NOTICE REQUIRED FOR (INSPECTIONS - PLEASE CALL (209) 95 76 <br /> 77 <br /> SIGNED TITLE //� . DATE ,//Z/ f' <br /> LEM <br /> A UI C U <br /> L <br /> �DPARTMENT US ONLY <br /> w,w <br /> Application Accepted By Date Area `�( Employee ID# <br /> Grout Inspection By n Date A I 1 SPECIAL Well Permit <br /> Pump Inspection By I a Date A 1_1 WAIVER Received <br /> Soil Boring Inspection By Date Constructed ell Depth ft <br /> COMMENTS <br /> PE SC ReceivedCheck# Amount Permit/ <br /> Co es Info B Cash emitted Date Service Re uest# Invoice# Well ID# <br /> 'r-- S o S <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />
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