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COMPLIANCE INFO
Environmental Health - Public
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EHD Program Facility Records by Street Name
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4 (STATE ROUTE 4)
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9355
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2900 - Site Mitigation Program
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PR0523365
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COMPLIANCE INFO
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Entry Properties
Last modified
11/20/2024 9:09:14 AM
Creation date
2/14/2020 4:42:38 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
2900 - Site Mitigation Program
File Section
COMPLIANCE INFO
RECORD_ID
PR0523365
PE
2950
FACILITY_ID
FA0015788
FACILITY_NAME
PETES PLACE
STREET_NUMBER
9355
Direction
W
STREET_NAME
STATE ROUTE 4
City
STOCKTON
Zip
95206
APN
13109021
CURRENT_STATUS
01
SITE_LOCATION
9355 W HWY 4
P_LOCATION
99
P_DISTRICT
003
QC Status
Approved
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EHD - Public
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#4821 WELL/ PUMP PERMIT•t ,I <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 4 304 E WEBER AVE 3"FL-STOCICTON CA 95T 209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209 -7697 FOR INSPECTIONS EXPIRES I YEAR FROM, L ISSUED <br /> JOB ADDRESS 9355 W. Highway 4 CITY/ZIP Stockton 95206 > <br /> CROSS STREET Delta Road APN 131-090-21 PARCELSIZE1 2 LAND USE APPLICATION N m <br /> OWNER NAME. AyeAh Ayesh OC PHONE 462-2976 <br /> OWNER ADDRESS BamP CITY/STATE/ZIP <br /> CONTRACTOR U.1tg�f111fi�S�hS.hfi Delta Stockton Pump PHONE M 466-9625 <br /> CONTRACTOR ADDRESS (a P.M'�LY1i1`.YL I{?( 646 S California St CITY/STATE/ZIP .Stockton, CA 95209 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS C7IIITY/STATAE/ZIP <br /> C3AM <br /> LICENSE C-57 &C-61 ❑D-09 ❑Other NUMBER EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X V Township Range Section <br /> INTENDED USF. ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Sal Sampling/Characterization <br /> ®Public Water System <br /> If different from wnec Water System Nam Lonuict Nam m <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other <br /> ❑Monitoring Well(s) #of wells ❑Soil Boring(s) .orboungs ❑Geotechnical "orbor�R. <br /> ❑Well Destruction ❑Out-Of-Service Wcll ❑Out-Of-Service Well Renewal <br /> ❑New Pump EKPump Replacement ❑Pump Repair ❑Cross-Connection Repair <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth B Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth. Il ❑Neal Cement(94//r hag/5-10 gad u•al,•r) ❑Sand Cement__ sack mix/7 gal water <br /> ❑Hcnionite(10%solids) ❑Mnnul'acnlrer Spec%solids_ % Name ❑Specs on File ❑Spccs Submitted r <br /> Grout Placement Method ❑Pumped ❑Frcc Fall ❑other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑Other r <br /> ❑Concrete Pedestal Dimensions: Width_ ft Length ft Thick in ❑Christy Bos ❑Stove Pipe <br /> PUMP 0 Submersible ❑Turbine ❑Other HP 1 Pump Set 30 ft Standing Water Level 10 R t% <br /> ❑ pen Bottom ❑Grave ack ❑Uncased 13 Other iZ <br /> Well Diameter in Total Depth 5 ft Depth to Water ft ❑Casing to be Perforated from ft to ft <br /> Scaling Material ❑Neat Cement(94)h hag/5.10 gal water) ❑Sand Cement .rack mix/7 gal water ❑Bentonite Pellets <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Placement Method ❑Pumped ❑Free Fall ❑Other <br /> ❑Complete with Mushroom Cap ft below grade ❑Complete to Existing Surface Pad <br /> 1 HEREBY CERTIFY THAT 1 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 /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS 09 10 04 <br /> SIGNED ----, TITLE �Yu CEO DATE <br /> i <br /> If n ,)nfi4 <br /> NV 7V <br /> / J <br /> DEPARTMENIr UISE ONLY 3/ <br /> Application Accepted Dy Date Area o2 r Employee ID# O)y 99 <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Destruction Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Remitted Service Request# <br /> 43.s< o5r t1�3 �sr,o 3�C( LU ��`, `1 C)/a>aS-7 I <br /> EIID 11A2-OOA MASTER WATER WELL PERMIT <br />
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