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WP0040958
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4200/4300 - Liquid Waste/Water Well Permits
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WP0040958
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Entry Properties
Last modified
11/24/2021 2:39:47 PM
Creation date
7/29/2020 3:01:46 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
WP0040958
PE
4372
STREET_NUMBER
3380
Direction
N
STREET_NAME
TRACY
STREET_TYPE
BLVD
City
TRACY
Zip
95376-
APN
21445001
ENTERED_DATE
7/9/2020 12:00:00 AM
SITE_LOCATION
3380 N TRACY BLVD
P_LOCATION
03
P_DISTRICT
005
QC Status
Approved
Scanner
SJGOV\tsok
Supplemental fields
CYEAR
2020
Tags
EHD - Public
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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 6232 1209)468-3420 <br /> NON•REFUNUMLE PERAWT www.sjgov.org/ohd EXPIRES 1 YEAR FROM DATE(ssuEo <br /> JOB ADDRESS 3380 North Tracy Boulevard CiTY/ZIP Tracy, CA 95376 rl <br /> D <br /> CROSSSTREET West Clover Road APN 214-450-01 PARCEL SIZE 044P LAND USE APPUCA11ON# o <br /> A <br /> OWNER NAME Jr)hp C;a rihalrli PHONE 209-466-6735 <br /> OWNERAODRESs 3255 Wet Marrh Lane-Suite 210 Crt MATI1101 tockton, CA 95219 <br /> CONTRACTOR West Coast Exploration PHONE 209-985-7541 <br /> CONTRACTOR ADDRESS P.0 Box 133 CITYISTATEmp ESCalon,CA 95320 <br /> SUBCONTRACTOR/CONSULTANT MatriScope PHONE 916-375-6700 <br /> SUBCONTRACTOR/CONSULTANT ADDRESS 601 Bercut Drive CRYISTATERJP Sacramento, CA 95811 <br /> LICENSE K C-57 D C-61 7 D-09 01744 NUMBER 1970761 ExPim-riONDATE 01/31/2022 <br /> BILLING PARTY: G OWNER U CONTRACTOR Y SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:0 General Mineral/Coliform Bacteria(4391)0 Dibromochloropropane(4392)U Arsenic(4393) <br /> INTENDED USE 0 DOmestic/Private 0 Irrigation/Agricultural D Indwtrililil ❑Water Quality Monitoring 0 Sail Sampling/Characterization <br /> O Public Water System <br /> It different from owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK O New Well ❑Replacement Well D Well Alleralion/Modification O Other <br /> ❑Monitoring Well(s) #of wells iK Soil Boring(s) 3 15ft O of borings 0 Geotechnical a of bonngs <br /> I-Out-Of-Service Well 0 Out-Of-Service Well Renewal O Cross-Connection Repair <br /> 0 New PUM D Pump Replacement 0 Pump Repair 0 Raise Well Cas <br /> WELL CONSTRUCTKIN <br /> Drilling Method n Mud Rotary n Air Rotary X Auger ❑Cable Tool D Push Point L Other <br /> Proposed well Depth 6 It Excavation in diameter D Open Bottom D Gravel Pack/Gravel Size in diti Mlef <br /> n Conductor Casing in diameter / Conductor Casing Depth n <br /> Well Casing Diameter_in Thickness/Gauge/ASTMSched ❑Steel 0 Plastic C Stainless Steel n Other <br /> Grout Seal Depth IS It X Neat Cement(94lbbag/5-10gal water) O Sand Cement _sack mixflgal watar <br /> -1 Bentonite(20%solids) O Other <br /> Grout Placement Method c Pumped I Free Fall O Other 0 Retardant/Accelerator(naafe) <br /> PEDESTAL Installed By ❑Driller O Pump Contractor ❑ Other <br /> 0 Concrete Pedestal DDimensions:Width it Length It Thick in n Chnitirty Box O Stove Pipe <br /> ❑Submersible Turbine 0 Other HP Pimp Set ft StandIN 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 48 HOUR ADVA NOTICE REQUIRED FO//R�(INSPECTIONS-PLEASE CALL(209-)%3-7687 V <br /> TITLE r/JSIS�JQi✓7' LJt/�//V1 - DATE N/Y/WA/120 <br /> III MEN7 <br /> Ec <br /> E/VED <br /> UL 09 20 <br /> A�J�RON <br /> j�ECOUNTY <br /> E H DEPgRTP ENT <br /> y� I JJ DEPARTMENT,/USE ONLY /f <br /> Application Accepted By �/� -6, Dale //fit 0110 Area / Employee ID# <br /> Grout Inspection By Date TTT' F SPECIAL Well Permit <br /> Pump Inspection By Date I i WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#) Amount Dae PerrnlU Invoice At Well ID# <br /> Codes Infq ash Remitted ServiceR(itusest <br /> La 7d "t-7 -7,90 <br /> EHU 43-06 61112019 4 WELL(PUMP PERMn <br /> 6t/ 1010 7s7/9 186 7 95D <br />
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