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WP0041901
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EMBARCADERO
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4200/4300 - Liquid Waste/Water Well Permits
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WP0041901
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Last modified
6/8/2021 9:45:11 AM
Creation date
6/8/2021 9:39:28 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
File Section
COMPLIANCE INFO
RECORD_ID
WP0041901
PE
4372
STREET_NUMBER
6545
STREET_NAME
EMBARCADERO
STREET_TYPE
DR
City
STOCKTON
Zip
95219-
APN
09827022
ENTERED_DATE
4/5/2021 12:00:00 AM
SITE_LOCATION
6545 EMBARCADERO DR
P_LOCATION
01
P_DISTRICT
002
QC Status
Approved
Scanner
SJGOV\dsedra
Tags
EHD - Public
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JOB ADDRESS <br /> 6545 EMBARCADERO DR <br />CITY/ZIP Stockton, CA 95219-3327 <br />CROSS STREET NI/A 6c.vvlir ApN 098-270-220-000 <br />PARCEL SIZE 3.0 LAND USE APPLICATION// <br />OWNER NAME <br /> PELLARIN ENTERPRISES ETAL <br />PHONE " <br />OWNER ADDRESS 1520 MAIN ST Orr/STATE/LP REDWOOD CITY CA 94063 <br />CONTRACTOR <br /> V & W Drilling, Inc. PHONE 209-469-7700 <br />CONTRACTOR ADDRESS 1133 BLACKHURST DR <br />SuecoNnucroft/CoNsul-TANY Wallace-Kuhl & Associates <br />SUBCONTRACTOR/CONSULTANT ADDRESS 3050 Industrial Blvd <br />CITY/STATE/ZIP Galt, CA 95632 <br />Cell 916-997-1546 <br /> PHONE Office 916-372-1434 <br />CITY/STATE/ZIPWest Sacramento, CA 95691 <br />LICENSE V C-57 I C-61 1 3-09 I Other <br />NUMBER 720904 EXPIRATION DATE 4/30/2022 <br />BILUNG PARTY: OWNER <br /> <br />CONTRACTOR <br /> <br />Nr SUBCONTRACTOR/CONSULTANT :SSMICICIV 311S 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 />DOMESTIC WELL SAMPUNG: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring V 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 <br /> <br />Well Alteration/Modification I Other <br />Monitoring Well(s) # of wells , Soil Boring(s) C ot bonngs II Geotechnical 1 # of bonngs <br />Out-Of-Service Well I Out-Of-Service Well Renewal 1 Cross-Connection Repair <br />New Pump I Pump Replacement 1 Pump Repair I Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method Mud Rotary Air Rotary V Auger Cable Tool Push Point Other <br />Proposed Well Depth 15 ft Excavation 8 in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Tftickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br />Grout Seal Depth 15 ft V Neat Cement (94 lb bag/5-10 gal water) Sand Cement sack mix/7 gal water <br />I Bentonite (20% solids) Other <br />Grout Placement Method I Pumped V Free Fall I Other I I Retardant / Accelerator (name) <br />PEDESTAL Installed By I Driller I Pump Contractor I Other <br />Concrete Pedestal I .Dimensions: Width ft Length ft Thick in Christy Box I Stove Pipe <br />PUMP Submersible Turbine Other HP 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 />WORK RS COMPENSATION LAWS. <br />INIMUM 48 HO ADVANC NOTICE REQUIRED FOR INSP CTIOV - PLEASE CALL (209). 1953 769 n <br /> T TLE f'V,1,,(' DATE I 1"". 'L-A <br />(-) Pif <br />/1 <br />>a° ft'cie "Ivr VI el) <br /> A g- <br />m ,a 49021 <br /> tAt\o`44) Azur lAirr 'IDEpAssivrAt <br />DEPARTMENT US ONLY <br /> <br />Application Accepted By •••••"--- Date <br /> <br />Grout Inspection By A Date IT <br /> <br />Pump Inspection By Date <br />Area aistx IA0" Employee ID# ri A <br />I SPECIAL Well Permit <br />WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS 1-c cli‘oils,CivNIC;Je+-) Ciico;ixl -if yed 4-yer3loek ripe <br />PE <br />Codes <br />SC <br />Info <br />Received <br />By <br />( Ches14/ ---Clish <br />Amount <br />Remitted ate a <br />Permit/ <br />Service RegHtst # Invoice # Well ID# <br />Li3L3 ]-0 Is 0107-( 620193 Li ,ts-4 1.0 11 tA ogvq-0 I <br />SIGNED <br />EHD 43-06 6/11/2019 WELL /PUMP PERMIT
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