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WP0041017
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MT DIABLO
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4200/4300 - Liquid Waste/Water Well Permits
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WP0041017
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Entry Properties
Last modified
11/24/2021 11:56:36 AM
Creation date
8/18/2020 7:57:20 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
WP0041017
PE
4372
STREET_NUMBER
350
Direction
E
STREET_NAME
MT DIABLO
STREET_TYPE
AVE
City
TRACY
Zip
95376-
APN
23511018
ENTERED_DATE
7/30/2020 12:00:00 AM
SITE_LOCATION
350 E MT DIABLO AVE
P_LOCATION
99
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•/OAOUIN COUNTY ENNRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(2091468-3420 <br /> NON-REFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> Joe ADDRESS 350 F ML Diablo Avenuepp CITY,ZIP T <br /> - raSy. CA 95376 <br /> r3e <br /> CROSS STREET Shakesar n Irt APN 235 O <br /> 1101 PARCEL SIZE LAND USE APPLICATION 3 <br /> OWNER NAME Tracy Unified School District PHONE 209-830-3200 <br /> owNFR ADDRESS __1875 W Lowell Avenue_ _ _ CfTYISTAmmp Tracy,CA 95376 <br /> CONTRACTOR Middle Earth Geo Testing, Inc. PHONE 714-633-5025 <br /> CONTRACTOR ADDRESS 954 N Lemon Street CITYISTATEIAP Orange, CA 92767 <br /> SUGCONTRACTMCONSULTANT RSK Associates PHONE 916-853-9293 <br /> SURCONT RACTMCONSUL TAN T ADDRESS 3140 Gold Camp Dr.#160 C"ISTATEmp Rancho Cordova,CA 95670 <br /> LICENSE X C-57 0.81 D-09 Other NUMIMR 899451 EXPIRATION DATE 06/30/2021 <br /> BILUNO PARTY: OWNER CONTRACTOR X SUSCOWRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE DomesliC'Ptwate Imgaaon'Agricultural Industrial Water ouabty Mon,tonng Y.Sat Sampling/Charactenzatlon <br /> PabLc Water System <br /> •CFM.r'1•rem JV..u• '•varer sista.-bre Corned Nemo a Ph"N-drTYPE OF WORK New Well Replacement WOO Well AIlerat,on Moddicabon Dow <br /> Monnonng WeIIIsI M of wells Sal BonnglsI e y t10r'"as X GeoteCMued_LR Or ' <br /> Out-Or-Serv,ce Well Out-Of-Serv,ce Well Renewal Crosti-CpnneetWn Repair <br /> Now Pump Pump Replacement Pump Repal, Rake Wap Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Ar Rotary X Auger Cable Tool Pusn POInt Other <br /> Proposed Well Depth 50 h E.c oahon 1.5 .n c,ameter Open Boeorn Gravel PacIVGraval Size in diameter <br /> ConOuctor Casing to dlamele• Conductor Casing Depth R <br /> Well Casing Diameter__ in ThicknesVGaugeiASTM Schee Steel Plastic Stainless Steal Other <br /> Grout Seal Depth �Q It Y.Neat Cement(94 lb batt'5-10 gal water) Sand Cement secir mW7 gal water <br /> Bunton,w 20`v solids; Other <br /> Grout Placement Method Puetpea Free Fell ;S Other CPT rods/Iremmle RetarCanl Accelerator(name) <br /> EMKI T& Installed By Dr1Eer Pump Contractor Other <br /> Concrate Pedestal Dlmanslons:Width h Length ft Thick In Christy Box Stove Pipe <br /> PUMP SuhmorsiDle Turbine Other HP- RIMP Set % Sta^ding Wntrr Le—t (I <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> ICAQUIN COUNTY ORDINANCES. STATE LAWS. AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND CTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL I <br /> i <br /> WORKERS C NSATION Lk - <br /> iMICC 'UANCE NOTICE U(RED F R NSPEC i ON -P E CALL(209 953-7697�/� <br /> SIGNEC TtTLF ATF -L-✓ •4� <br /> F yMENT <br /> CES V F� <br /> C 3 2420 <br /> Pq0 Nr4�NTY <br /> RT A)v <br /> DEPARTMENT U E ONLY <br /> Application Accepted By � Date7 30 aO^Q Area 5 TI4;� Employee 100 Sk <br /> Grout Inspection By Date SPECIAL Well Permit <br /> PumpInspection By A Date WAIVER Received <br /> Sol Borhg Inspetfbn By 14 k 66te g 3 Constructed Well Depth <br /> COMMENTS <br /> PE SC Re"hod AngMM PetTnW <br /> Cedes Info Rend fad DaftPe <br /> R Nate Invoke t won o t <br /> 31 �0 <br /> END43-0e dtt40te WELL0t"PEnaT <br />
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