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WP0039425
EnvironmentalHealth
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EHD Program Facility Records by Street Name
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26 (STATE ROUTE 26)
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28251
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4200/4300 - Liquid Waste/Water Well Permits
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WP0039425
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Entry Properties
Last modified
11/20/2024 8:50:33 AM
Creation date
10/17/2019 10:11:14 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
WP0039425
PE
4369
STREET_NUMBER
28251
Direction
E
STREET_NAME
STATE ROUTE 26
City
LINDEN
Zip
95236-
APN
06723001
ENTERED_DATE
3/12/2019 12:00:00 AM
SITE_LOCATION
28251 E HWY 26
P_LOCATION
99
P_DISTRICT
004
QC Status
Approved
Scanner
SJGOV\tsok
Supplemental fields
CYEAR
2019
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)468-3420 <br /> AON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS rI d- ✓/ C= /��'� G�� CITY/ZIP �a' m <br /> D <br /> ROSS STREET d�� APN Ob�,Z3o O_I PARCEL SIZE `7� !1) LAND USE APPLICATION# 0 <br /> OWNER NAME ''N <br /> t PH/ONE <br /> 'j _s 2.�- <br /> 410 <br /> OWNER ADDRESS ��V n/" CITY/STATE/ZIP7r�� <br /> CONTRACTOR I xiA <r n PHONE J -,f '7L <br /> CONTRACTOR ADDRESS �ii t� 1 -72 CITY/STATE/ZIP 4a <br /> SUBCONTRACTOR ' / .1—r PHONE <br /> SUBCONTRACTOR ADDRESS ZCITY/STAT�pE/Z�IP <br /> LICENSE �I-C-57 1 C-61 D-09 I I Other NUMBER J ?9 ' " EXPIRATION DATE �' 1 <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE ❑ Domestic/Privat Irrigation/Agricultural ❑ Industrial 1 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 /> 0 Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings I Geotechnical #o ED <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair $ <br /> ew Pump ❑ Pump Replacement C Pump Repair ❑ Raise Well Casing 2 e l4 <br /> WELL CONSTRUCTION "ANJOAQuI <br /> NC <br /> Drilling Method +�dVlud Rotary ❑ Air Rotary I I Auger ❑ Cable Tool I I Push Point 0 Other 14PAI—`�®N%l,I`r � . <br /> Proposed Well/Depth �,�� ft Excavation �� in diameter I I Open Bottom .KGravel Pack/Gravel Size `T'��I'Vblf or <br /> 1 Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter 5 in Thickness/Gauge/ASTM Sched -1 'Q 1l Steel ><Plastic 11 Stainless Steel ❑ Other <br /> Grout Seal Depth ft ❑ Neat Cement(94 Ib bag/5-10 gal water) I>Sand Cement sack mix/7 gal water <br /> 11 Bentonite(20%solids) ❑ Other <br /> Grout Placement Method Pumped ❑ Free Fall I I Other I l Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller ❑ Pump Contractor. ❑ Other <br /> ❑ Concrete Pedestal Li Dimensions:Width ft Length ft Thick Jn I Christy Box _ Stove Pipe <br /> PUMP ,rte Submersible❑ Turbine 1-1 Other HP 1-0 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 /> MINIMUM 4R HOUR AD , NCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br /> SIGNED /� .?�. TITLE C"C/r✓��� DATE J -it <br /> yL ' <br /> +1 <br /> U <br /> Z <br /> EY R 11`x1 EN T USC 0NLY <br /> Application Accepted y Date ?/ Area Employee ID# <br /> Grout Inspection By Date I'M ❑ 1 PECIAL Well Permit <br /> Pump Inspection By Date_ 1 WAIVER Received <br /> Soil Boring Inspection By Date- Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check!/ Amount Date Permit/ Invoice# Well ID# <br /> Code& Info Elyn '-Cssli Remitted Service Reg uest# <br /> c 2 <br /> EHD 43-06 8/01116 WELL/PUMP PERMIT <br />
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