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WP0039269
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ESCALON BELLOTA
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13883
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4200/4300 - Liquid Waste/Water Well Permits
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WP0039269
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Entry Properties
Last modified
6/13/2019 10:44:44 AM
Creation date
6/12/2019 3:30:00 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
WP0039269
PE
4380
STREET_NUMBER
13883
Direction
S
STREET_NAME
ESCALON BELLOTA
STREET_TYPE
RD
City
ESCALON
Zip
95320-
APN
20733006
ENTERED_DATE
2/7/2019 12:00:00 AM
SITE_LOCATION
13883 S ESCALON BELLOTA RD
P_LOCATION
99
P_DISTRICT
004
QC Status
Approved
Scanner
AGooderham
Tags
EHD - Public
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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468.1420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB AoDRE35 C-���,7 i:1 V 1 $6\0C, AQ. CTfY0 ESC(cal i 1'ti�0 m <br /> rr \ A ff11 �1 D <br /> CROSS STREET G c�.,Jc.0 AJt� APN U ♦✓ PARCEL S¢E LAND USE APPLICATION# <br /> OWNER NAME �`��p�T1i:(� �VI�M��\h PHONE <br /> OWNER ADDRESS {{, L7(.�� t�C.f`G� T)C�`C+�'\ Q, CnY/STATEIZIP Est-c ACri). (Or '1532V <br /> CONTRACTORurMGG�,,� ZhC./L PHONEC1I�^%'�•� <br /> CONTRACTOR ADDRESS a G1 tG 5& aY%rar , 1442 . CITY/STATEIZIP��Cc 10�\r Ga 0153ay <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS Crry/STATE/(Z,IP <br /> LICENSE 5(C-57 F-C-61 D-09 in Other NUMBER IC;LJL LC1 EXPIRATION DATE 3 CJ\ <br /> DOMESTIC WELL SAMPUNG:n General Mineral/Coliform Bacteria(4391)❑Dibromochloropropane(4392)n Arsenic(4393) <br /> INTENDED USE —AC/Private L Inigation/Agricultural a Industrial Water Quality Monitoring L Soil Sampling/Characterization <br /> F1 Public Water System <br /> Ir daerenl bom Owner: Waley System Name ConWd Name a Plane Number <br /> TYPE OF WORK a New Well a Replacement Well a Well Alteration/Modification a Other <br /> n Monitoring Wells) #of wells n Soil Boring(s) A or bO ings n Geotechnical s or borings <br /> L Out-Of-Service Well u Out-Of-Service Well Renewal u Cross-Connection Repair #y� <br /> New Pum n Pu Replacement n Pu Repair n Raise Wei CasingI" <br /> WELL CONSTRUCTION yk <br /> Drilling Method n Mud Rotary n Air Rotary n Auger n Cable Tool n Push Point n Other �4►����� <br /> Proposed Well Depth it Excavation in diameter n Open Bottom n Gravel Pack/Gravel Sae in dia <br /> ConF® <br /> n Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thidmess/Gauge/ASTM Sched n Steel n Plastic n Stainless Steel n Other o,�D/ <br /> Grout Seal Depth ft n Neat Cement(94 Ib bag/S10 gal water) n Sand Cement sack mixx hga / QU/h J9 <br /> n Bentonite(20%solids) n Other L, <br /> Grout Placement Method n Pumped n Free Fall n Other n Retardant/Accelerator(name) pq Fj1/q�& <br /> PEDESTAL Installed By Driller Pump Contractor Other o v�-C,-- <br /> n Rr <br /> Concrete Pedestal na Da +d 4-\ <br /> imensions:Width ft Length ft Thick in n Christy Box n Stove Pipe MINT <br /> P I>eSubmersible a Turbine a Other HP_! Pump Set klk6_ft Standing Water Level <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 UCENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED DATE �J <br /> Z <br /> 1 J <br /> J <br /> a <br /> V <br /> U <br /> N <br /> ARTMENT U E j6NLY ! <br /> Application Accepted By Date 0 Area Employee ID# <br /> Grout Inspection By Date J PECIA Well Permit <br /> Pump Inspection By Date ���0��\� WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Receive-4 C Amount Date PertniV Invoice# Well 1D# <br /> Codes Into Cash Remitted Service R uest# <br /> 1— 2-1- <br /> EHD43-06—.d4/14118 WELL/PUMPPERMIT <br />
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