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WP0041314
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4200/4300 - Liquid Waste/Water Well Permits
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WP0041314
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Last modified
3/2/2021 2:41:57 PM
Creation date
3/2/2021 2:38:14 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
WP0041314
PE
4381
STREET_NUMBER
11600
Direction
E
STREET_NAME
MARIPOSA
STREET_TYPE
RD
City
STOCKTON
Zip
95215-
APN
18106025
ENTERED_DATE
10/7/2020 12:00:00 AM
SITE_LOCATION
11600 E MARIPOSA RD
P_LOCATION
99
P_DISTRICT
001
QC Status
Approved
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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 (209)468-3420 <br /> NON-REFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS CITY/ZIP CA qsat:S7 <br /> m <br /> CROSS STRE wz— APN l �7 V PARCEL SIZE +� / LAND USE APPLICATION# a <br /> OWNER NAME PHON17W �n rl LI01 a+ <br /> OWNER ADDRESS �(%1 CITY/STATE/ZIP U L.� <br /> CONTRACTOR c v ma vis PHONE-2 �31 L2_04(jam.<< <br /> CONTRACTOR ADDRESS CITYISTATE/ZIP <br /> SUBCONTRACTOR/CONSULTANT P NE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS TY/STATE/ZIP / <br /> LICENSE C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER EXPIRATION DATE �l <br /> BILLING PA TY: ❑OWNER ❑CONTRACTOR ❑ SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)❑ Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ 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 /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of borings <br /> ❑ Out-Of-Service II ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> ❑ New Pump Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method D Mud Rotary ❑ Air Rotary ❑Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth ft ❑ Neat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal❑Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP Submersible❑ Turbine ❑ Other HP Pump Set ft Standing Water Level ft <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 LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MI H cDVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)l959-7p7 <br /> / <br /> SIGNED TITLE /f � DATE <br /> rA <br /> 71,270 <br /> t L&UV ___1q <br /> rV <br /> N F <br /> a DEPARTMENT USE ONLY TMENT <br /> Application Accepted By GDate D Area �� Employee ID# F1� <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By "A%S Ic (12-j(,1- 9:L Date 1)j'22-19s%1,) ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Amount Permit/ <br /> Codes Info By as Remitted Date Service Re uest# Invoice# Well ID# <br /> 38) 050 �77 10-1-241 Qi4 <br /> EHD 43-06 6/11k2019 WELL/PUMP PERMIT <br />
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