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SU0009679
Environmental Health - Public
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SU0009679
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Entry Properties
Last modified
5/7/2020 11:34:09 AM
Creation date
9/8/2019 12:43:33 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
2600 - Land Use Program
RECORD_ID
SU0009679
PE
2690
FACILITY_NAME
PA-1300102
STREET_NUMBER
9631
Direction
E
STREET_NAME
PELTIER
STREET_TYPE
RD
City
ACAMPO
Zip
95220-
APN
00735006 & 10
ENTERED_DATE
6/25/2013 12:00:00 AM
SITE_LOCATION
9631 E PELTIER RD
RECEIVED_DATE
6/24/2013 12:00:00 AM
P_LOCATION
99
P_DISTRICT
004
QC Status
Approved
Scanner
SJGOV\rtan
Supplemental fields
FilePath
\MIGRATIONS\P\PELTIER\9631\PA-1300102\SU0009679\APPL.PDF \MIGRATIONS\P\PELTIER\9631\PA-1300102\SU0009679\CDD OK.PDF \MIGRATIONS\P\PELTIER\9631\PA-1300102\SU0009679\EH COND.PDF \MIGRATIONS\P\PELTIER\9631\PA-1300102\SU0009679\EH PERM.PDF
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EHD - Public
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WELL/PUMP PERMIT <br /> '/"SAN JOAQUIN COUNTY ENVIRONall HEALTH DEPARTMENT SIM E WERER AVE JIM FL-STOCNTON CA"Mt (Sb9)"B&M" <br /> NON-REFUNDABLE P --"' L CALL 2/09.957-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> /1 <br /> JOBADDRESS lO �F/I-i [/� Cm/7J9. OtA�" `�' N/ <br /> CRDeS STREET L- (,�.I1y1 y5 .,/AAP�N LII�-367V` f PAMZEELS/�IZE /7 �_ 8 <br /> OWMERNAME � '+ ✓. �l� V / 1 PHOJ�NE F ✓1 d''A /�J R <br /> OWNERADPREES CITY/STATE/EI? <br /> CuMnKAIR ay V1 -yVt"t) PHONE, 13 oil-Alf <br /> '/ <br /> CITYMI'ATP2IP 00Jq 221 / ` iCOHrRAcrOR aoOREss <br /> 5 <br /> — <br /> SUBCONTRACTOR PHONE <br /> SUeCONTRwCTORADDRM CITYISTATFJLIP <br /> LICENSE C-57 0C-61 0D-09 ❑Other NUMBER ENHRATIDBDATE may <br /> GCOQRAnItCAL INPORMwT10Nt CoordIrMW X Y Township_ Rao,, Section_ <br /> INTENDED USE ❑D0meaic/P1.AM O IrripdoNAg,Kulwnl ❑Industrial ❑Water Quality Monitoring ❑Sod Sanpli.wCh.cur rine <br /> 0P.1,1"Water yshom <br /> m raaM <br /> TYPE OF WORE New Well ❑Pepkcement Well O Well AllentioNModifteation Died Hole OOrher (, <br /> Monitoring Well(,) .Soil Borings) auwh«erbadogr nGeoseemicai maritalkadnp �� <br /> ❑We Destruction D Out-0r Service Well ❑Out-Of-Service Wtll Renewal g:J <br /> ❑New Pum D Pum lacenrcm ❑Purn,RcpMr <br /> O Crons Conneonon Repair <br /> WRLLCONSEROLTI N ... <br /> Drilling Me= RMud Rote DA ir ROH.ry ❑Ar ❑Cabk Tool 13 Nan Point ❑Other <br /> Proposed Well 0.pIM1 ft Pacavuion in diameter ❑Open Bamm O.Crate Pick/Grave)Size mriameler , <br /> ❑ameter Conductor Coding In diameru / Cordu sonDnE DepN A ! <br /> Well Casing Diameter yt in Thick.UCauge/ASTM Schad V ❑Steel Plsgic ❑Sinl HeI ❑Otba <br /> Groin Seal Depth�V It n�cas Cement fP[lh bag/J-]0 gal water) Sark Cement 3 vak wh/7 Sol water <br /> DBentonite(20%solids) D Manufacturer Spee%solids % Name ❑Specson File OSpect SubmluW <br /> Crout%attmem Melh.d PumpM ❑Free Fall DOdmr ❑RmardantlAecelencer(rucre <br /> PEDESTAL n I.H. B tiller n Pump ConI.W D O,her <br /> Conteh Pedestal Dimensions: Width ft Length_B Thick in ❑Christy Boz nSmve Pipe <br /> PUMP Wubmetsible nTurbiue DOther HP Pump Sa ft SurWing Wuer Level ft <br /> WELL Dessaut TtoN ❑Open B.E. D Gm.el Peck ❑Uncosed O Other <br /> Wel Diemera in Total Depth R Depth to Water ft D Casing m be Perlbrated from_B 1._R <br /> Sea,Material ❑Neat Cement(9l/b bug/5-/0grd wafer) ❑S vd Cemml mak MIS 17 gal water ❑Ben euthe Pellets <br /> ❑Economic(2M solids) ❑Manufacterer Spee%solids_% No ❑Specs..Fifa ❑Specs Submitted <br /> Placement Mahood O Pumped tl Free Fall D Other <br /> ❑Complete with Mushroom Cap A below grade ❑Canplele m Existing Surface Pad <br /> 1 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. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> INIMUM 24 HOUR ADVANCE NOTICEnRE�Q,/Uy)IR�ED�POR INSPECTIONS <br /> sIQIaED + n <br /> TITLE DATE <br /> iV/ DATE 7 c <br /> 1 <br /> N <br /> N <br /> a NT USE. Y yy{.4, <br /> Application Accepted By Dale �, Aro 7Employee IDA,-fs 02P <br /> Grout Inspection BY Dam - ❑ SPECIAL Well Permit k1 Tee <br /> Pump Inspection By ✓L'L�._ Date (r D 13WAtveR Received ! 4 <br /> DnuucUm In Tan B Date Co slruekvl WeII D,th R <br /> COMMENTSd) 'ZOO j19.eteE.Al` (yi) (T2 e ` 79 rCLn7e04t,,, <br /> PE SC A...f Chasm R. arlDate Permit/ I E.i..a Well IDE <br /> Codes tufo Remitted ask B sameatR <br /> 6N, sMf1 001 <br /> n Roo 4b3 <br /> EHD43-02-006 M6-_FR-d O6? • ,,) MASTER WAI Ea-ELL PERMIT <br /> snrzooz 949Q E �j{ipro <br /> 007-350-oq <br />
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