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4200/4300 - Liquid Waste/Water Well Permits
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WP0043321
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Entry Properties
Last modified
7/20/2022 10:06:19 AM
Creation date
7/20/2022 9:57:05 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
WP0043321
PE
4372
STREET_NUMBER
831
Direction
W
STREET_NAME
CLOVER
STREET_TYPE
RD
City
TRACY
Zip
95376-
APN
21418043
ENTERED_DATE
5/24/2022 12:00:00 AM
SITE_LOCATION
831 W CLOVER RD
P_LOCATION
03
P_DISTRICT
005
QC Status
Approved
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EHD - Public
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I WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN-KEFUNDABLE PERMIT GALL (209) 953-1697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 831 W. Clover Road CITY/Zipp Tracy , 95376 <br />CROSS STREET N Tracy Blvd APN 214-18-043 PARCEL SIZE • `LAND USE APPLICATION # <br />OWNER NAME <br />OWNER ADDRESS <br />Anshuman Sehdev Ah r; Rar`llilnhpnS Adm I f imat O n f401I) IML PHONE 209.676.1846 <br />831 W Clover Road CITY/STATE/ZIP Tracy, CA 95376 <br />CONTRACTOR Korbmacher Engineering Inc <br />CONTRACTOR ADDRESS 480 Preston Ct. Suite B <br />SUBCONTRACTOR Exploration Geoservices, Inc. <br />SUBCONTRACTOR ADDRESS 563 Asbury Street <br />LICENSE X C-57 ❑ C-61 ❑ D-09 <br />PHONE 925.454.9033 <br />CITYISTATE/ZIP Livermore , CA 94551 <br />PHONE (408) 280-6822 <br />CITY/STATE/ZIP San Jose, CA 95110 <br />❑ Other NUMBER '4'84288 EXPIRATION DATE 12/31/2023 <br />DOMESTIC WELL SAMPLING: a General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) E Arsenic (4393) <br />INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural D Industrial ❑ Water Quality Monitoring X 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 ❑ Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(S) # of borings YE Geotechnical 2 # of bot P <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair Fq YM <br />❑ New Pump ❑ PumD Replacement ❑ PumD Repair ❑ Raise Well Casina <br />WELL CONSTRUCTION ,1 V w <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary X Auger ❑ Cable Tool ❑ Push Point ❑ Other RA <br />2,6 <br />Proposed Well Depth 30 ft Excavation 0 in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size A A, In diame <br />❑ Conductor Casing in diameter I Conductor Casing Depth ft f / ,c� � ON C <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Othel' -- O <br />Grout Seal Depth Full—depth ft X Neat Cement (94 lb bag/5-10 gal water) ❑ Sand Cement sack mikFAijiR <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />❑ Concrete Pedestal ❑Dimensions: Width ft Length ft Thick <br />n ❑ Christy Box ❑ Stove Pipe <br />PUMP ❑ Submersible❑ Turbine ❑ Other HP Pump Set ft Standing Water Level It <br />Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect to the following items: GPS <br />Coordinates, property lines, adjoining properties, water bodies or courses, drainage pattern, roads, existing wells, structures, <br />potential sources of contamination, sewers or private disposal systems. Include distance from two property lines. For Domestic, <br />Agriculture, Industrial well, provide location of any water wells or surface water within 200' radius of proposed well. <br />MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />DEPARTMENT USE ONLY <br />Application Accepted By Date S .7 om <br />Grout Inspection By Date <br />Pump Inspection By Date / <br />Soil Boring Inspection By �1 . L'"'` Date �o 17 <br />COMMENTS <br />Area S f c Employee ID# A S <br />-1 SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth <br />PE SC Received Check#/ Amount Date Permit/ Invoice # Well ID# <br />Codes Info B Cash Remitted Service est # <br />ft <br />EHDO43-06 04/07/2022 Page I of 2 Well / Pump Permit <br />( � W- l4fS-77sq(�, <br />T <br />1 <br />M <br />D <br />0 <br />0 <br />M <br />tl T <br />U <br />
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