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SR0070647
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120 (STATE ROUTE 120)
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4200/4300 - Liquid Waste/Water Well Permits
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SR0070647
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Last modified
11/19/2024 4:01:31 PM
Creation date
3/5/2021 8:56:38 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
SR0070647
PE
4369
STREET_NUMBER
11006
Direction
E
STREET_NAME
STATE ROUTE 120
City
MANTECA
Zip
95336
APN
22803026
ENTERED_DATE
9/29/2014 12:00:00 AM
SITE_LOCATION
11006 E HWY 120
P_LOCATION
99
P_DISTRICT
003
QC Status
Approved
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Tags
EHD - Public
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WELUPUMP ('ERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> to <br /> JOB ADDRESS CITY/ZIP '^�" / m <br /> a <br /> Z�� p M <br /> CROSS STREET APN Z PARCEL SIZE J� LAND USE APPLICATION# m <br /> En <br /> OWNER NAME /%� 1/`/�J <� PHONE v 1751 <br /> N <br /> OWNER ADDRESS CITY/STATE/ZIP a <br /> CONTRACTOR `/Y7"/ '^' Lf �/`�'^�� - ��- PHONE ✓�� ��� <br /> CONTRACTOR ADDRESS /20 <br /> �/ / IE►G�-LJy� /` -/ — CITY/STATE/ZIP _5641--v <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE -57 C-61 D-09 Other NUMBER EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y 1 AA I T <br /> T s p ` Section, <br /> INTENDED USE Domestic/PrivateIrrigation/Agricultural Industrial ftM4r I y n orin it SAn1plfhMMcterization <br /> Public Water Syst C�rmif m �J}1 vo nvniro� rn>'ithnt a <br /> If different from Owner: Water System Name r Imlay haye CTd7i4i)� w €cjl b�• ber <br /> A <br /> TYPE OF WORK Slew Well 1 Replacement Well Well Alteration/Md Iba i dpi olmas '' <br /> Monitoring Well(s) #of wells Soil Boring(s) _ by��i.!;m ff I fLrua� c�yjs on #of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal _1 Cross-Connection Repair <br /> /-New Pump i Pump Replacement i Pump Repair i Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Vmud Rotary ��Air Rotary Auger i Cable Tool Push Point I Other <br /> Proposed Well Depth�ft Excavation in diameter Open Bottom ravel Pack/Gravel Size in diameter <br /> I Conductor Casing in diameter / Conductor Casin Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched G�ZG i i Steel/�QPlastic i Stainless Steel Other <br /> Grout Seal Depth. A,ft i Neat Cement(94 Ib bag/5-10 gal water) Sand Cement sack mix/7 gal water <br /> X Bentonite(20%solids) Other <br /> Grout Placement Method Pumped ' Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By I DrillerPump Contractor <br /> Concrete Pedestal I Ali-m*ensions:Width ft l-erNi ft Thick in Christy Box Stove Pipe <br /> PUMP Submersible Turbine Other HP_ �Z5 Pump Set ft Standing Water Level <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 COMP SATION LAWS. <br /> MINI R NCEENNO.TICE REQUIRED FOR IN PECTIONS- PLEASE CALL(209)95/3-7p97 <br /> SIGNED �l� TITLE DATE 2-o <br /> h <br /> H �• <br /> U <br /> kXLam. <br /> G A — <br /> 1 <br /> [ a <br /> i <br /> NN T <br /> �—. <br /> n r I A V . -14i Z <br /> 7 <br /> IL__9 I I . . . . <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Area Employee ID#TuGl�� <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date _ Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Cash Remitted Service Request# <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4/30/12 <br />
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