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WP0041678
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4200/4300 - Liquid Waste/Water Well Permits
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WP0041678
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Entry Properties
Last modified
4/14/2021 12:18:30 PM
Creation date
4/14/2021 10:25:23 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
WP0041678
PE
4368
STREET_NUMBER
13744
Direction
S
STREET_NAME
CASTLE
STREET_TYPE
RD
City
MANTECA
Zip
95336-
APN
19712007
ENTERED_DATE
2/3/2021 12:00:00 AM
SITE_LOCATION
13744 S CASTLE RD
P_LOCATION
99
P_DISTRICT
003
QC Status
Approved
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SJGOV\tsok
Tags
EHD - Public
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Application Accepted By <br />Destruction Inspection By <br />COMMENTS <br />X--z <br />DEPARTMENT <br />Employee ID# /45 <br />Area --Vgq <br />USE <br />Date <br />Date <br />WELL DESTRUCTION PERMIT <br />PUBUC WATER SYSTEM f: Yes No <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue -SrocicroN CA 95205-6232 - (209)468-3420 <br />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS <br />JOB ADDRESS 137 Q q ,cer, <br />CROSS STREET rt.damci K <br />/ <br />APN /1 7-)20-0 147 <br />OWNER 7145 <br />OWNER ADDRESS ,c^-1.-1 b CITY/STATE/Zip <br />CONTRACTOR ii'tfr fry &lel-re-1 49471/1"7", PHONE 2(9 ,-6/7 —0 41 1(1--- <br />CONTRACTOR ADDRESS 0 on fi crryisTATEmp pie cc e GA_ • 47,s rq o <br />/P o 2I1Ci <br />PHONE <br />PERFOFATION CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> <br />EXPIRES 1 YEAR FROM DATE ISSUED <br />CITY/Zip /AtirrecA_ CC qcr 3c <br />PARCEL SIZE /PC LAND USE APPLICATION # <br />PHONE 201 - 2oq 9O2o <br />C-ST WELL DRILUNG LICENSE NUMBER <br />PERFOFAT1ON CONTRACTOR <br />EXPIRATION DATE <br />0 C-57 Well Drilling <br />Bureau of Alcohol, Tobacco and Firearms - Users of High Explosives <br />CHP Hazardous Material Transportation for Explosives <br />San Joaquin County Sheriff-Coroner Explosives Application and Permit <br />California Occupational Safety Health - Blaster <br />License Number Expiration Date <br />License Number Expiration Date <br />License Number Expiration Date <br />License Number Expiration Date <br />License Number Expiration Date <br />1 zri <br />I <br />REASOF FOR DESTRUCTION 0 Dry fir Replacement Well <br />Detected / Suspected Well Water Contaminant(s) <br />Adjacent property with contamination (Address) <br />Known Soil / Water contaminants at adjacent property <br />El Caved In El Pit Well El Inactive Test Hole <br /> <br />EXISTING WELL CONSTRUCTION DETAILS 0 Open Bottom 0 Gravel Pack 0 Uncased 0 Other <br />Well Log copy attached 0 Yes fX No Grout Seal 0 No 0 Yes ft below ground surface (bgs) Hole Diameter <br />Well Conductor Casing 0 Yes lg No Depth of Conductor Casing <br />Well Casing Diameter Sr inches Total Depth ...14457Q Depth to Water ,,ZO ft Depth of Casing <br />ft bgs Diameter of Conductor Casing <br />inches <br />inches <br /> ft bgs <br />DESTRUCTION SPECIFICATION <br />Sealing Material from 0 ft bgs to 4'.<6. ft bgs <br />Well casing to be perforated by one of the followina methods: from ft bgs to ft bgs <br />Mills Knife Number of cuts every ft and I or <br />Explosives 0 Detonating cord -0 with projectiles every <br />0 Detonating cord and boosters 0 with projectiles every <br />Other <br />Seali ig Material Neat Cement (94 lb bag / 5-6 gal water) ,k Sand Cement /4 , 3 <br />Bentonite (20% solids) Manufacturer Spec % solids ''/. Name <br />Isg <br />Filler Material Jo , SArre, from ft bgs to ft bgs <br />ft <br />ft <br />sack mix / 7 gal water Bentonite Pellets <br />Specs on File Specs Submitted <br />without projectile <br />without projectile <br />Placement Method u ped Free Fall Other <br />Seal Completion X Complete with Mushroom Cap ft bgs Complete to Existing Surface Pad <br />I HERE3Y 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 />CONTRACTORS SIGNATURE <br />MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br />col% ret.e-rZ1 <br /> TITLE )L/'1 er DATE 2 -2 -2 / <br /> <br />I <br />"4.- <br />_ . I (cV tie) ,f <br />" , <br />oc <br />,6) <br />. t--1 <br />1 , <br />I T Th <br />1 11 r 1 I I I I_ Fl I I-1-1 ' <br />' i021 <br />I <br /> <br /> 0,4) 041 <br />I 1 1.164Cr °ONA,E;11 COU 41), <br />PAP '14 7-4/00. <br />PE <br />Codes <br />SC <br />Info <br />Received <br />By <br />Check#/ Amount <br />Remitted Date , <br />Permit/ <br />Service Request # Invoice # Well ID# <br />14,3‘e O'C' <br />Cast) <br />UaK . <br />PS-0R 1-13/2-1 VIC0/062 'W <br />EHD 43-08 <br />revised 4/14/18 :121AotLQ3' 1191 WELL DESTRUCTION PERMIT
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