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WP0039571
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4200/4300 - Liquid Waste/Water Well Permits
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WP0039571
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Entry Properties
Last modified
7/31/2019 10:32:01 AM
Creation date
7/24/2019 1:07:11 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
WP0039571
PE
4374
STREET_NUMBER
2619
STREET_NAME
DIABLO VIEW
STREET_TYPE
DR
City
MANTECA
Zip
95337-
APN
24178029
ENTERED_DATE
5/1/2019 12:00:00 AM
SITE_LOCATION
2619 DIABLO VIEW DR
P_LOCATION
04
P_DISTRICT
005
QC Status
Approved
Scanner
TSok
Tags
EHD - Public
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WELL DESTRUCTION PERMIT <br /> r PUBLIC WATER SYSTEM ❑Yes ❑No <br /> ♦ SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205-6232-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(20919532J697 FOR INSPECTIONS PIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS Z I t (t,b U 7V.,c � .IP J ?,7-7 <br /> T <br /> CROSS SIMET -J�+ M(�r ! •� /� APN �GT(� 7 PARCEL SIZE_LAND USE APPLICATION# <br /> OWNER tK9Arc �Q`C a"1 D(.� PHONE A <br /> OWNER ADDRESS ID 7� CITY/STATE/ZIP v <br /> CONTRACTO �f C. PHONE45'— 'Y2 /6� <br /> CONTRACTOR ADDRESS J , CITYISTATE/ZIP C I x7 J <br /> C-57 WELL DRILLING LICENSE NUMBER Cl V S / EXPIRATION DATE <br /> PERFORATION CONTRACTOR PHONE"C2 (���j <br /> PERFORATION CONTRACTOR ADDR SPA Y1J��jj/B CITY/STATE/ZIP � • �J 1774 <br /> 4 <br /> I/ C-57 Well Drilling License Number 1Y 21 8 �rv�n Dates J/•/ <br /> Bureau of Alcohol,Tobaccoand Firearms-Users of High Explosives License NumbeY 04 1/�J xpirahon Date/#?- .20 <br /> CHP Hazardous Material Transportation for Explosives License Number 74W 7 Expiration Date�/.19� <br /> San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number l dOle Expiration Date(_,/q <br /> California Occupational Safety Health-Blaster License Number .J o*)( Expiration Date/i.29./f <br /> REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well active ❑ Test HolePA <br /> Detected/Suspected Well Water Contaminant(s) <br /> Adjacent property with contamination(Address) ,RF ,M�e•T <br /> Known Soil/Water contaminants at adjacent property Ve6 <br /> EXISTING WELL CONSTRUCTION DETAILS ❑ Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other k Y ® 1 219 <br /> Well Log copy attached ❑ Yes E'No Grout Seal ❑ No ❑ Yes ft below ground surface(bgs) Hole Diameter inches <br /> Well Conductor Casing❑ Yes ❑ No Depth of Conductor Casing ft bgs Diameter of Conductor Casing inches IV JOAQUIN <br /> Well Casing Diameter inches Total Depth ft Depth to Water ft Depth of Casing it b R Cot <br /> DESTRUCTION SPECIFICATION � LTH )EPARrT� ry <br /> Sealing Material from -_ft bgs to Z I ft bgs Filler Material.:'OA CIDP f from 90 ft bgs to� ft bgs "46N 7' <br /> Well casing to be perforated by one of the following methods: from 0 ft bgs to 2^ ft bgs <br /> ❑ Mills Knife Number of cuts every ft and/or <br /> &-Explosives❑ Detonating cord ❑ with projectiles every / ft ❑ without projectile Gj/�J •A <br /> ❑ Detonating cord and boosters ❑ with projectiles every L�ft 13 without projectile %[ ! <br /> ❑ Other <br /> Sealing Material Neat Cement(94 Ib bag/5-6 gal water) Sand Cement/Q, sack mix 17 gal water Bentonite Pellets <br /> Bentonite(20%solids) Manufacturer Spec%solids_% Name Specs on File Specs Submitted <br /> Placement Method 4�Pumped Free Fajl,t Other - <br /> Seal Completion-0� Complete with Mushroom Cap �3 ft bgs Complete to Existing Surface Pad <br /> I HEREBY CERTIFY THAT 1 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 WITA THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION WS. <br /> NIM .7A ANCE NOTICE REQUIRED FOR INSPEC IONS 4 <br /> CONTRACTORS SIGNATURE TITL DATE 11 <br /> o WW R ale. <br /> I ..... l.__ <br /> f <br /> �.. -.,___., i...� ....... <br /> ....._i..._....i..__...e.____e__....i �_....,_ _ <br /> r.... .._.,._,........ <br /> i <br /> o Q. <br /> ... Y _ <br /> T M E N T USE ONLY <br /> Application Accepted ByJ)(11�4 Date <br /> J Area ! C� ' 1 l `elt. <br /> Destruction Inspection B ate .S Employee ID# <br /> COMMENTS <br /> PE SC Received Che Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Cash Remitted Service Request# <br /> CJ,H <br /> EHO 43-08 WELL DESTRUCTION PERMIT ` <br /> revised 4/14/18 <br />
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