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WP0041604
EnvironmentalHealth
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4200/4300 - Liquid Waste/Water Well Permits
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WP0041604
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Entry Properties
Last modified
12/21/2021 2:43:23 PM
Creation date
12/21/2021 2:07:17 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
WP0041604
PE
4380
STREET_NUMBER
25753
Direction
N
STREET_NAME
TULLY
STREET_TYPE
RD
City
ACAMPO
Zip
95220-
APN
02103033
ENTERED_DATE
1/12/2021 12:00:00 AM
SITE_LOCATION
25753 N TULLY RD
P_LOCATION
99
P_DISTRICT
004
QC Status
Approved
Scanner
SJGOV\tsok
Supplemental fields
CYEAR
2021
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 <br />www.sjgov.org/ehd <br />EXPIRES 1 YEAR FROM DATE ISSUED <br />jj <br />JOB ADDRESS �J / j_ 7 N <br />I Li 11 D CITY/LP <br />A( o M )1 ( t 15 �0 <br />r,� j �' ` <br />5c(- <br />CROSS STREET L III I Pi^ D <br />�--Io tJYPARCEL SIZE <br />C LAND USE APPLICATION # <br />'tIZ <br />OWNER <br />OWNER NAME t/ e V L� I • S <br />�'`A�P/N{ 1yVJ. <br />7/ P 1 I ' `,- <br />PHONE <br />S <br />OWNER ADDRESS n e <br />CITY/STATEIZIP <br />CONTRACTOR \j 611 I �( ' J <br />^ 1 1 \ 1 h �I <br />PHONE -77�� <br />CONTRACTOR ADDRESS U I� C <br />X CITYISTATEIZIP <br />U-.6"1 A <br />SUBCONTRACTOR/CONSULTANT <br />PHONE <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />CITY/STATE/ZIP <br />LICENSE ',Iq-57 C-61 D-09 <br />Other NUMBER <br />EXPIRATION DATE <br />BILLING PARRTY: OWNER <br />AONTRACTOR f1 SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) L Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE XDomestic/Pnvate _ Imgatlon/Agricultural Industrial ❑ Water Quality Monitoring - Soil Sampling/Characterization <br />L Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK X New Well i Replacement Well Well Alteration/Modification Other <br />D Monitoring Well(s) # of wells Soil Boring(s) # of bonogs , Geotechnical # of borings � / <br />D Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair ,/ <br />WELL CONSTRUCTION c�V <br />Drilling Method, Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br />Proposed Well Depth 3 ft Excavation �� in diameter I Open Bottom X Gravel Pack/Gravel Size 114 - in diamet <br />ConductorCasing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter C9 in Thickness/Gauge/ASTM Schede 2G Steel APlastic Stainless Steel Other <br />Grout Seal Depth 1'1 ft Neat Cement (94 lb bag/5-10 gal water) i Sand Cement I (: sack mix/7 gal water <br />Bentonite (20% solids) I Other <br />Grout Placement Method APumped J Free Fall Other Retardant / Accelerator (name) <br />PEDESTAL Installed By '. Driller i Pump Contractor Other <br />Concrete Pedestal I0imensions: Width c2 It Length --7— ft Thick n i Christy Box Stove Pipe <br />PUMP `S4 Submersible Turbine Other HP S Pump Set 2a!�i ft Standing Water Level 1 S G 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 />MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />DEPARTMENT USE Ory LY <br />n <br />Application Accepted By Date ( I z <br />Grout Inspection By Dete -Zi i0 <br />Pump Inspection By Date. <br />Soil Boring Inspection By <br />COMMENTS <br />Date <br />1220 <br />21 <br />%R -rAk � <br />9Rr�FNr <br />Area L (I Employee ID# <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth 15 ft <br />EHD 43-06 6/112019 WELL /PUMP PERMIT <br />
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