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t <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-769 F PECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS Quail Lakes(Alexandria&5 Mile Slough) L } rµ`a CITY/Zlp Stockton 95206 m <br /> D <br /> CROSS STREET Alexandria PI APN 11206067 PARCEL SIZE 0.33 acres LAND USE APPLICATION# o <br /> m <br /> m <br /> OWNER NAME City of Stockton Municipal Utility Dept. Job#M16010 PHONE 209-937-6700 <br /> OWNER ADDRESS 2500 Navy Drive CITY/STATE/ZIP Stockton CA 95206 <br /> CONTRACTOR Farwest Corrosion Control PHONE 510-952-6256 <br /> CONTRACTOR ADDRESS 2223 Commerce Place CITY/STATE/ZIP Hayward CA 94545 <br /> SUBCONTRACTOR nla PHONE n/a <br /> SUBCONTRACTOR ADDRESS n/a CITY/STATE/Zip rile <br /> LICENSE IZIC-57 E]C-61 [::]D-09 Other NUMBER 248232 EXPIRATION DATE 12-31-2019 <br /> DOMESTIC WELL SAMPLING:-General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392)C Arsenic(4393) <br /> INTENDED USE Domestic/Private LLImo- ngation/Agricultural ndustrial -Water Quality Monitoring --Soil Sampling/Characterization <br /> Public Water SystemJJ <br /> It different from Ovmer Water System Name Contact Name or Phone Number <br /> TYPE OF WORK v/ New Well - Replacement Well =Well Alteration/Modification ✓ Other Cathod6c Protection <br /> 0 Monitoring Well(s) #of wells oil Boring(s) #of borings - Geotechnical #of bonngs <br /> = Out-Of-Service Well C Out-Of-Service Well Renewal - Cross-Connection Repair <br /> _. New Pum - Pump Replacement D Pump Repair - Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Ovlud Rotary 04ir Rotary -Auger :-Cable Tool =Push Point 1:1 Other <br /> Proposed Well Depth 45 fill Excavation in diameter - Open Bottom Lj ravel Pack/Gravel Size in diameter <br /> -_ Conductor Casing n/a in diameter / Conductor Casing Depth n/a ft <br /> Well Casing Diameter L in Thickness/Gauge/ASTM Sched PVC Sch 80 ❑Steel - Plastic - Stainless Steel 111ther <br /> i <br /> Grout Seal Depth ft [Z]Neat Cement(94 Ib bag/5-10 gal water) -Sand Cement sack mixr7 gal water <br /> - Bentonite(2 %solids) -Other <br /> Grout Placement Methodr+ runrped =Free Fall =Other Tremmie = Retardant/Accelerator(name) <br /> PEDESTAL Installed By Griller -Pump Contractor L.�j Other Mon.—I <br /> =Concrete Pedestal-Dimensions:Width ft Length ft Thick in -Christy Box - Stove Pipe <br /> PUMP C Submersible=Turbine - Other N/A HP NIA Pump Set N/A It Standing Water Level--NA ft <br /> I HEREBY CERTIFY THAT I.HQVE 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 WITH, <br /> l <br /> Ml lMU 48 R AT NQC N TICE REQUIRED FOR GS)PECT NS PLEASE CALL(209)W-769,7 <br /> SIGNED Tt � <br /> / DATE <br /> S E E P L A N S F O R D E T A I L S <br /> T <br /> D <br /> ` 19 <br /> LINTY <br /> --tit Yff I AL <br /> ENT <br /> ^'I DEPARTMENT USE O LY <br /> . q <br /> Application Accepted By r Date 1 Area Employee ID# <br /> Grout Inspection By Date / SPECIAL Well Permit <br /> Pump Inspection By Date _ WAIVER Received <br /> Soil Boring Insp ction By Date Constructed ell 0 th <br /> CO MENTS-" . 1 Y 9 1: r it SC CI Lt E2 r✓� C Gr Th <br /> PE SC Received ec 'mount Date Permit/ Invoice# Well ID# <br /> Codes Ino B Remitted Service Request# , <br /> ?i ' '751q111 3 <br /> EHD 43-06 revised 4114:18 WELL/PUMP PERMIT <br />