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WP0042134
EnvironmentalHealth
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12 (STATE ROUTE 12)
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4200/4300 - Liquid Waste/Water Well Permits
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WP0042134
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Entry Properties
Last modified
11/19/2024 3:48:26 PM
Creation date
10/24/2022 2:59:20 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
WP0042134
PE
4380
STREET_NUMBER
10943
Direction
E
STREET_NAME
STATE ROUTE 12
City
LODI
Zip
95240-
APN
05115049
ENTERED_DATE
6/9/2021 12:00:00 AM
SITE_LOCATION
10943 E HWY 12
P_LOCATION
99
P_DISTRICT
004
QC Status
Approved
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Tags
EHD - Public
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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN-KEFUNDABLE PERMIT <br />GALL (ZUU) 8Z�f-/byy FOR INSPECTIONS tAY1Kt5 T TEAR FROMDATE ISSUED <br />JOB ADDRESS Will <br />� E s <br />4'. k )t (, <) it I ; <br />CITY/2.IP L i. I5,210 <br />CROSS STREET tU <br />Trt +-y) -'P- k I K VAPN <br />ARCEL SIZE LAND USE APPUC/AtTION # <br />OWNER NAME <br />1u� <br />1y� <br />CA M 1 �Z <br />PHONE <br />-7�`1 - /C� y� <br />CQr <br />o �� <br />OWNER ADDRESS <br />CITY/STATE/ZIP <br />CONTRACTOR �1 ^I'�jI <br />(^� <br />L�%I/r I'1 <br />I^(1 C1 <br />PHONE <br />/ <br />Cul �4'�I R7 /-7[7 <br />I <br />P C' 5 C' .1 <br />: J <br />CITY/STATEIZJP C ( 17) <br />CA q 5GS D <br />CONTRACTOR ADDRESS <br />JC <br />SUBCONTRACTOR <br />PHONE <br />SUBCONTRACTOR ADDRESS CITYIStTATE/ZIP <br />LICENSE /,C-57 -_ C-61 D-09 Other NUMBER �ClL1 3 S 3 EXPIRATION <br />7 ,-;, --� <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section <br />NTENDED USE )<,Domestic/Pdvate - Inigation/Agricultural -i Industrial J Water Quality Monitoring i Soil Sampling/Characterization <br />Public Water System <br />If different from Owner Vft.r ys em ame G..td No— or Phhe N..bol <br />TYPE OF WORK New Well Replacement Well Well Alteration/Modification J Other <br />Monitoring Weil(s) # of wells Soil Boring(s) # of bonngs -I Geotechnical %ef borings <br />Out -Of -Service Well r Out -Of -Service Well Renewal i Cross -Connection Repair <br />New Pump Pump Replacement - Pump Repair :7 Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method -)kud Rotary _ Air Rotary _- Auger Cable Tool Push Point I Other <br />Proposed Well Depth 350 ft Excavation 1. in diameter - Open Bottom )f Gravel Pack/Gravel SizeyA - in diameter <br />7 Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter S2_ in Thickness/Gauge/ASTM Sched c 1'7i 0 tSteel'y(, Plastic C Stainless Steel IOther <br />Grout Seal Depth Voo ft _ Neat Cement (94 Ib bag/5-10 gal wafer) }KSand Cement (U • 7 sack mixR gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method . Pumped L Free Fall L Other Retardant / Accelerator (name) <br />PEDESTAL Ipstalled By 14Dnller Li Pump Contractor I Other <br />jC Concrete Pedestal rIDlmensions: Width ft Length ft Thick in -1 Christy Box r1, Stove Pipe <br />PUMP '/Submersible- Turbine - Other HP 7 ' Pump Set cZc7J ft Standing Water Level 14Ci 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 <br />24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 V <br />SIGNED / yu! f'CV �1�� TITLE . C C r r i1 DATE <br />/rte <br />rn <br />D <br />0 <br />A <br />y <br />pAYME <br />heck#/ <br />Cash <br />Amount Date pennIV <br />Invoice # <br />Remitted Service Re uest# <br />JUN ' rsr�l■■■■■■■■■■■■■■■■nI■■■■■i■■■■■■■■i■■■■■■■■■■� <br />... a■■W■■■■■■■■■■■■■■■■I■■■■moi■■■■■■■■i■■■■■■■■■■i■ <br />P RTMENT USE NLY h % ) ` t ^� <br />Application Accepted By Date Area �;2 v �T Employee ID#� <br />Grout Inspection By Date ZI ] SPECIAL Well Permit <br />Pump Inspection By Date <br />Z— <br />Pump WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth �0 tt <br />COMMENTS _--- '; 'S I A It S, L - 1-1 (• - ) \ Icd. -"�- - -- <br />Info <br />EHC 43-08 <br />4reon <br />¢30 v 9D <br />heck#/ <br />Cash <br />Amount Date pennIV <br />Invoice # <br />Remitted Service Re uest# <br />WeIIID# <br />o �� <br />�� <br />WELL/PUMP PE MIT- _ <br />
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