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WP0039159
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4200/4300 - Liquid Waste/Water Well Permits
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WP0039159
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Entry Properties
Last modified
5/21/2019 8:44:07 AM
Creation date
5/20/2019 3:59:17 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
WP0039159
PE
4372
STREET_NUMBER
19100
STREET_NAME
CHRISTOPHER
STREET_TYPE
WAY
City
LATHROP
Zip
95330-
APN
19813019
ENTERED_DATE
1/3/2019 12:00:00 AM
SITE_LOCATION
19100 CHRISTOPHER WAY
P_LOCATION
07
P_DISTRICT
003
QC Status
Approved
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DAfonskaia
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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 /> LA <br /> JOB ADDRESS 1 L70 L h1 a CITY/ZIP /✓K r0,4 ' r�r <br /> CROSS STREET iri APN I``n'I O / 1 <br /> PARCEL SIZ LAND USE APPLICATION# op <br /> m <br /> OWNER NAME PHONE w <br /> OWNER ADDRESS CITY/STATE/ZIP y <br /> CONTRACTOR Lid k <br /> `L {y�,(� '7 <br /> ]HCONE p` t.�y�r�� J�1' <br /> CONTRACTOR ADDRESS-7,0Q)��. �1 �, V_r`-' 1 r� --0 CITY/STATEZP L5 ✓!y(t S,VV/�h�I 0 <br /> SUBCONTRACTOR I i f 4e I, /r�It L) Co. PHONE vJlu <br /> V <br /> SUBCONTRACTOR ADDRESS V�O V�I Cr1�r ✓ CITY/STATEZP P',/ <br /> LICENSE /C-57 D C-61 ❑D-09 ElOther NUMBER,"o EXPIRATION DATE 3o <br /> DOMESTIC WELL SAMPLING:0 General Mineral/Coliform Bacteria(4391)0 Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE ❑Domestic/Private 0 Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring f Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK '.I New Well ❑Replacement Well ❑Well Alteration/Modification 0 Other <br /> ❑Monitoring Well(s) #of wells 0 Soil Bodng(s) #of borings W1 Geotechnical #of borings <br /> ❑Out-Of-Service Well 0 Out-Of-Service Well Renewal 0 Cross-Connection Repair <br /> 0 New Pump ❑Pump Replacement D Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method j(Mud Rotary D Air Rotary /Auger Cable Tool ❑Push Point ❑ Other <br /> Proposed Well Depth 50 ❑ft Excavation in diameter ❑Open Bottom 0 Gravel Park/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth It <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad D Steel 0 Plastic n Stainless Steel ❑Other <br /> Grout Seal Depth ft Neat Cement(94 lb bag/5-10 gal watet) ❑Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) ❑Other <br /> Grout Placement Method IPumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor 0 Other <br /> ❑Concrete Pedestal❑Dimensions:Width ft Length It Thick in 0 Christy Box ❑Stove Pipe <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 /> M 48ADV NCE NOTICE REQUIRED FO I PECTIONS_-APLEASE CALL(209) 5 -7 7 <br /> SIGNED TITLE G �/7 C r 7I-DATE �/ <br /> PARTMENT/U E O LY <br /> Application Accepted By Date ! 3 ( � Area p oyeelD# <br /> _A(A <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date i WAIVER Received PAYMENT <br /> Soil Boring Inspection By Date Constructed Well Depth <br /> COMMENTS <br /> PE Sc Received Check#/ Amount Permit/ pl <br /> Codes Inf B Cash emitted Date ice Re uest# Invoice# Well I N I f u <br /> JA�ySAN JOA NN COUNTY <br /> EMENTAL <br /> EPARTMENT <br /> EHD 43-06 revised 4114/16 WELL/PUMP PERMIT <br />
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