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WP0042283
EnvironmentalHealth
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4200/4300 - Liquid Waste/Water Well Permits
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WP0042283
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Entry Properties
Last modified
9/16/2022 10:51:40 AM
Creation date
9/16/2022 10:29:39 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
WP0042283
PE
4369
STREET_NUMBER
2700
Direction
W
STREET_NAME
MANCUSO
STREET_TYPE
RD
City
TRACY
Zip
95304-
APN
23905019
ENTERED_DATE
7/13/2021 12:00:00 AM
SITE_LOCATION
2700 W MANCUSO RD
P_LOCATION
99
P_DISTRICT
005
QC Status
Approved
Scanner
SJGOV\tsok
Supplemental fields
CYEAR
2021
Tags
EHD - Public
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SAN JOAQUIN <br />.-------COUNTY------ <br />Environmental <br />------COUNTY----- <br />Environmental Health Department <br />Well #2 Information <br />Use of Well: <br />❑ Domestic ❑ Irrigation ❑ Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑ Stock <br />❑ Other: <br />Total Depth (ft): <br />Distance To Nearest (ft): <br />❑ Open Bottom or Screen Interval (ft): <br />To: From: <br />Casing Diameter (in): <br />Wastewater Treatment System: <br />To: From: <br />Pumping Rate (gpm): <br />e . $OD <br />To: From: <br />Annual Extraction Volume (acre-feet: <br />Pond/Lake: <br />❑ Estimated ❑ Measured <br />Sewer Lines: <br />Specific Capacity (gal/min/ft): <br />Stream/River: <br />C',rt . 1 O, <br />Animal of Fowl Enclosure: <br />Other Pumping Tests Performed: <br />Test Result: <br />Well #3 Information <br />Use of Well: <br />❑ Domestic ❑ Irrigation ❑ Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑ Stock <br />❑ Other: <br />Total Depth (ft): <br />❑ Open Bottom or Screen Interval (ft): <br />To: From: <br />Casing Diameter (in): <br />To: From: <br />Pumping Rate (gpm): <br />To: From: <br />Annual Extraction Volume (acre-feet: <br />❑ Estimated ❑ Measured <br />Specific Capacity (gal/minlft): <br />Other Pumping Tests Performed: <br />Test Result: <br />WATER TABLE INFORMATION <br />Depth (ft): Source of Reference: Date of Reference: <br />Current Water Table: <br />Highest Water Table: <br />Lowest Water Table: <br />Recharge Area: Recharge Rate: <br />SITING INFORMATION <br />Distance To Nearest (ft): <br />Onsite: Offsite: <br />Distance To Nearest (ft): <br />Onsite: Offsite: <br />Wastewater Treatment System: <br />c4, <br />Transmission Lines: <br />e . $OD <br />Onsite Well: <br />,_y4 , 1600 <br />Pond/Lake: <br />N Ift <br />Sewer Lines: <br />c), <br />Stream/River: <br />C',rt . 1 O, <br />Animal of Fowl Enclosure: <br />IV 10T <br />MAP INFORMATION <br />A map of the well location must be attached to this form and shall include the following information: <br />• Legal lot and parcel dimensions. <br />• All well locations on legal lot and parcel with type and use information shown for each well. <br />• Distance from proposed well to any potential sources of pollution onsite and on adjacent properties, including: <br />o Existing or proposed onsite sewage treatments stems, wells, animal or fowl enclosures, transmission lines, sewer lines. <br />o Distance from ponds, lakes, and streams within 300 feet. <br />o For wells below Corcoran clay, map must show location of canals, ditches, pipelines, utility corridors, and roads within two miles. <br />I hereby certify that the information I have provided is accurate and truthful to the extent reasonably known. <br />Signed: ��-rr,xu�,.uV 8�,. (� 0 4a "by 5 '" Date: -j- Z —2.1 <br />Information Provided By: <br />Well Driller ❑ Well/Property Owner ❑ Other: <br />EHD 4300 12-21-2017 2 of 2 <br />
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