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WP0041776
EnvironmentalHealth
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EHD Program Facility Records by Street Name
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12 (STATE ROUTE 12)
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10696
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4200/4300 - Liquid Waste/Water Well Permits
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WP0041776
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Entry Properties
Last modified
11/19/2024 3:48:25 PM
Creation date
6/29/2021 11:54:38 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
WP0041776
PE
4369
STREET_NUMBER
10696
Direction
E
STREET_NAME
STATE ROUTE 12
City
LODI
Zip
95240-
APN
05114003
ENTERED_DATE
3/10/2021 12:00:00 AM
SITE_LOCATION
10696 E HWY 12
P_LOCATION
99
P_DISTRICT
004
QC Status
Approved
Scanner
SJGOV\tsok
Supplemental fields
CYEAR
2021
Tags
EHD - Public
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Installed By 'Driller El Pump Contractor E Other <br />1_1 Concrete Pedestal El Dimensions: Width <br /> <br />1- El ft Length ft Thick in Christy Box CI Stove Pipe <br />SIGNED TITLE 0 — <br />MINIMU 48 HOlADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />DATE S <br />WELL/PUMP PERMIT <br />SAN SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAzEtiToN 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 /0 6 (IN /6-7 /L <br />CROSS STREET 711evii ei- 6.J 1-4-7 APN 05 I - IVO - 0 <br />OWNER NAME /3,2/ /54/c-4 -1(0/-, <br />OWNER ADDRESS <br /> <br />CITY/STATE/ZIP <br />CITY/ZIP II C <br />PARCEL SIZE .2-0 LA.ND Up/PPLICATION # <br />7 • ,) PHONE :SSalCICIV 3.1.1S CONTRACTOR /---/ 6::'/2c 4/^) <br />CONTRACTOR ADDRESS ey,e <br />SUBCONTRACTOR/CONSULTANT 64..g: 77 7 GPXJ-Cr R"1/1- <br />CITY/STATE/ZIP <br />PHONE SP—'*'.3*-S. 72j <br />itApeertiPT,r <br />PHONE 3 2_27 - 3 <br />SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP <br />LICENSE KC-57 El C-61 Li D-09 Li Other <br />NUMBER ,) k_367-5- <br /> <br />EXPIRATION DATE 6- <br />BILLING PARTY: OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE El Domestic/Private kfIrrigation/Agricultural El Industrial LE Water Quality Monitoring El Soil Sampling/Characterization <br />El Public Water System <br />If different from Owner: <br />TYPE OF WORK .)C. New Well E Replacement Well U Well Alteration/Modification El Other <br /># of wells El Soil Boring(s) # of borings <br />0 Geotechnical <br />0 Out-Of-Service Well Renewal Cross-Connection Repair <br />SAN j, WELL CONSTRUCTION <br />Drilling Method )e-Mud Rotary Li Air Rotary 0 Auger E Cable Tool El Push Point E Other <br />El <br />Hp.4,"ViROiViiiru°UNryi <br />Proposed Well Depth '353 ft Excavation /V in diameter Open Bottom 34 Gravel Pack/Gravel Size DPARr....' isvgjyreter <br />ycNew Pump C] Pump Replacement 11 Pump Repair <br />0 Monitoring Well(s) <br />0 Out-Of-Service Well <br />Water System Name <br />El Raise Well Casing <br />Contact Name or Phone Number PAN <br />_R ockistfE0 <br />AttIR 10 2021 <br />El Conduc,tgr Casing in diameter / Conductor Casing Depth <br /> <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched 0 Steel <br />Grout Seal Depth 7i-Chit)1 El Neat Cement (94 lb bag/5-10 gal water) <br />El Bentonite (20% solids) E Other <br /> <br />Grout Placement Method Pumped Free Fall El Other ElRetardant / Accelerator (name) <br />ft <br />Plastic El Stainless Steel Other <br />Sand Cement /0 ' <br /> sack mix/7 gal water <br />.eNgiubmersibleD Turbine El Other HP 70 Pump Set ft Standing Water Level <br />PEDESTAL <br />PUMP ft <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 COMPENSATION LAWS. <br />,Atit <br />.)e itt <br />0 <br />Th <br />/Ex..p.LR -r MENT USE ONLY <br />„ <br /> <br />Application Accepted By Date 3 (0/7,d)-/ Area / Employee ID#4MOV7 i <br /> <br />Grout Inspection By .Er'evu... ) C.' (9 i.--cif-, ei-m^:/- Date WZ-1,72E9Z f PECIAL Well Permit <br />Pump Inspection By rf\Esiti -/ C" CZANC; N P011'"" Date kg (zi WAIVER Received <br /> <br />Soil Boring Inspection By Date Constructed Well Depth qv c ft <br />COMMENTS 1 E:_-7E--1 7C-f7 <br />PE <br />Codes <br />SC <br />Into <br />Received <br />B <br />CSIsigil c#4/ <br />Cash <br />Amount <br />Remitted Date Permit/ <br />Service Request # Invoice # Well ID# 4.)/m. 4.0 25-r2_- :*.4-0 10 ,2-1 bopQ0141 <br />/1-3ta ov.4 1 1 2__ 3 101 tA400 LI ilq--7 <br />I <br />EHD 43-06 6/11/2019 <br />WELL /PUMP PERMIT
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