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SU0012668
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SU0012668
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Entry Properties
Last modified
12/8/2022 4:33:44 PM
Creation date
12/6/2019 10:13:03 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
2600 - Land Use Program
RECORD_ID
SU0012668
PE
2609
FACILITY_NAME
PA-1900278
STREET_NUMBER
37222
Direction
S
STREET_NAME
BIRD
STREET_TYPE
RD
City
TRACY
Zip
95304-
APN
26508015
ENTERED_DATE
12/5/2019 12:00:00 AM
SITE_LOCATION
37222 S BIRD RD
RECEIVED_DATE
7/5/2022 12:00:00 AM
P_LOCATION
99
P_DISTRICT
005
QC Status
Approved
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APPLICATION FOR WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br />(209) 468-3420 <br />WON-REFUNDARLE PERMIT EXPIRL!_1_YEAR FROM DATE 133UED <br />IC@IRpiET@ In TTIpIIe■TBl <br />AM PCATION M NEKE NY MADE TO THE VAN JOAOMN COUNTY FOR A PERMIT TO CONSTRUCT ANTIIOR INSTALL THE WORT( N)EECRIRFO. TIIIS APRICATION If MAI* M COMPOIANCE "TRI SAN <br />JOAOUIN COUNTY DEVELOPMENT TITm CHAPTEN 1)• 1 119.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HFALTH @EFIVICES, ENVR70NMENTAL HEALTH DM@ION. <br />JOS ADOFFSSKM APNI 3%Ji]� Li . �i.�_C/ /ZC7 CITY a PARCEL S4ElAPN/ cJ1.•J`'c' c' <br />OVIMER'S NAMEl-/IZ►�.4�% d �Ci�-�j ,�. .: �.- ADORES• <br />CONTRACTOR fi7�^w �.�[-ajiLn.'i�i.7 AODpEet �-aL: wee://n iF.✓ Ijt f.r,_1n.L'• LIC/"%%r �/N::� (i10NE /i�-/�. <br />SUV CONTIMCTO11 i �.r." �7/Zill �� [: AOOIFt/G%c% Com%. /'�G�s.: � • R' LOCI �%� L��110NE I!.•G ti- /S%LS" <br />1p�RT c " <br />SOP WELGPUMF, f6f NEW WELL f❑7 REP ACEMENT WELL ❑ MONITORNNO WELL • tt❑tt OTHER <br />❑ INSTALLATION Q WELL SYSTFRA PAPAIR ❑ CROSS -CONNECT REPAIR 1J VAPOR EXTRACTXIH WELL 0— <br />N. 11 <br />Now❑ RIP•L• N.P. DfPt11 PUMP SET FT. FIRST WATER IFVFL O <br />II YPE OF PIUMPI <br />❑ OUTdF-SERVICE WELL ❑ nF.nMIYSICAL WFLL f _. ❑ SOIL BORING S <br />❑ DESTRUCTIOM <br />INTENDED USE <br />® INDUSTRIAL <br />❑ DOMESTICNRVATE <br />❑ P USLICMUINICIPAL <br />❑ INFIIOATFON/AO <br />TYPi OF WELL <br />❑ OPEN BOTTOM <br />®GRAVEL PACKMIZE <br />❑ ORIVF PI <br />❑OTHER <br />CONSTRUCTION SPECIFIGAlIo <br />DIA_ OF WFLL EKCAVATION r� �' <br />TVPE.OF CAVNnUSTEELA"VC T4/1;? -� <br />DEPTH OF ORDUT PEAL / G'1.^ / ' 1V <br />GROUT SEAL NST ALLEN) i hC:�7: r_ <br />A <br />DIA, OF CONDUCTOR CA"M n <br />DIA. OF WELL CABINO re- -' D <br />SFTCWtCATION <br />GROUT GRAND NAME F <br />❑ MONITORING p <br />APVMX- O[P7/T CT 4'C� ,� i [=C S.` _ <br />U qBBY <br />ORDUT REAL PUMP FO! (N Y- <br />LOCARM CHESTER <br />❑ N• <br />BOXIOTOVE PIPE <br />CONCRETE PEDESTAL BY DFRLER: ❑ Y•• ®I/• S <br />i -7L -Y," <br />PROPOSED CoNSTTRUCrIoNUOFELUNO METHOD: MUD ROTARY_ V/ AIR ROTARY <br />ALWR <br />CABLE OTHER <br />I HERESY CERTIFY THAT I IIAVE P EPAFFO TWO APPUCATION AND THAT THE WORK WILL BE DONE N ACCORDANCE WI FH SAN JOAQUIN COUNTY ORT)1NANCEB. STATE LAWS, AHO RULEB AMO <br />REQULATIONS OF TNF SAN JOAOVN "KIlf". HOME OWNER ON LICENSED AOENT'B SIONATUIIE CEIITFFES THE FOLLOWING! '1 CERTIFY THAT IN THE P'ERFOFSAANCE OF TIRE WORK FOR WHICH <br />IMS PEFBAIT IB ISSUED, 1 SMALL NOT EMPLOY PERSONS SUBJECT TO WOMWAN'S COMPENSATION LAWS OF CALFOIMA.' CONTRACTOR'S MFvNO OR SUB -CONTRACTING VRINATURF CERTNFTES <br />THE FOLLOWING: ' 1 CERTIFY THAT N 711E PEFWOFIMANCE Of THE WORK FOR WHICH THIS PFFIWT IS IEVUEO, I SHALL EMPLOY PERSONS SUBJECT TO WORNMAN'S COMPENSATION LAWS OF <br />CALROINIA-'' THE A►PL)CANT MUST CALL 24 HOLVA IN ADVANCE FoR ALL PEOIwtrn INBPECTFON■ AT 1`700I ASS -5422. COMPUTE DRANRNO AT LOWER AREA PROVIDM- <br />eFow'E"r ,! i� y Vii. ,i liz r e. a..Tro. Otto il�lc' i <br />PLOT RAN Fbtnw I• Selly SIM• '10 <br />I- HANIXG OF STREET@ OR ROADS NEAREST to oR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SFWAI.TE DISPOSAL BYETFTA nit PEIPOSED <br />2" OUTLNE OF THE PgRRTY. NMVNO DAIENSFONS AND FORTH DIRECTION. EXPANSION OF SEWAGE bIVPOSAI SYSTEMS. <br />3. DMAETRMdflD OUTI1140-0, AND LOCATION OF ALL EXWrWM AND PROPOSED S. LOCATION OF WELLS WTTTNN RADIUS OF ONE HUNDRED FFrY R. <br />STRUCTURES, NCLODMO COVEFib AREAS SUCH AS PATIOS, ORIVEWAYS, AND WALKS. ON THE PROPERTY OR ADJOWINIS PROPERTY. <br />... ?. n... ....'r...... i..... ..... <br />SERVIC[MEMO i NMI© <br />INDUSTRIAL WELL- PROPU'Sl",L IS VEHY DCCT' 800-1(100 FEET BGS SJC W -LL 5TAI DARDS 4.2.1. _ <br />4.4.31'4.6-4111) 4.7.' AFPLY. PILOT HOLE TC EXTEI,ID THRGUGH THE PRf1 ;,OPAL CONFINING UtN'1 " <br />CORCOR.01 CLAY" MEMBER C= THE TULAR E FORMAT 10N ALSO K1rOWY N AS THE E -C' AAS <br />DESCRIBED 6'Y THE U55S HY; F10LOG)C4L ;,)VEST'DATICINS.4TLAS 7.',U'B 1995 RASED UPON <br />E -LOG BY DRIL-ER ANNULAR SEAL MUS71 EXTEND INT O ',HE E-CLAY,INTERCHANGE OF WATER <br />BET'wEEN FORMATIO1JS VIAWELLS AS A ?.ESULT OF WELL CONSTRUCTION SHOU'-D 1`10T OCCUR, <br />SEE PAGE 6, FZURE H2O= DWR \F/ATER WELL STANDARDS DULLETIN 74.81 DECE,"IBER 1981. <br />OEPMTMENT USE ONLY <br />AFPn•111•n Arnralmal S►Yom/ (PVlyt. _ _N).1• <br />O'.wA 9--tlsn By _ 1T� Otto 11rnF 1-11— Sr , �. ,D•t• <br />coolmelten <br />C tl.nenaMr: <br />Col <br />S <br />V --n T'vt- ., AAA <br />t�i�h� NnA.G ARA�NbRu,tiu.rl�- rvLe�nq <br />ACCOUNTING ONLY: AIDF FAC <br />PE CODES FEE ILIO AMOUNT ROWITED I CHECKP ASH RECEIVED SY <br />DATE PEEIrStlE INVOICE <br />t0030(109 <br />1 g v <br />Pub 4BBIth SBrv. • EDvwo, 173 (1,97) <br />
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