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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 /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> LA <br /> JOB ADDRESS West Ln Calaveras North Pump Station CITy/ZIp Stockton 95209 M <br /> D <br /> CROSS STREET West Ln.8 Calveras River Bike Ph ApN 10437009 PARCEL SIZE 0.29 acres LAND USE APPLICATION# o <br /> z <br /> m <br /> OWNER NAME City of Stockton Municipal Utility Dept. Job#M16010 PHONE 209-937-8700 m <br /> OWNER ADDRESS 2500 Navy Drive CITY/STATEZP 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 n/a PHONE n/a <br /> SUBCONTRACTOR ADDRESS n/a CITYISTATEZP n/a <br /> LICENSE Z✓ C-57 [:]C-61 ❑D-09 D Other NUMBER 248232 EXPIRATION DATE 12-31-2019 <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)❑Dibromochloropropane(4392)0 Arsenic(4393) <br /> INTENDED USE Domestic/Privategation/Agricultural Ljnclustrial D Water Quality Monitoring D Soil Sampling/Characterization <br /> Public Water% II <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well D Replacement Well D Well Alteration/Modificetion ✓ Other <br /> ❑Monitoring Well(s) #of wells Soil Boring(s) #of borings D Geotechnical #of bKngs <br /> D Out-OF-Service Well D Out-Of-Service Well Renewal D Cross-Connection Repair <br /> D New Pump D Pump Replacement D Pump Repair D Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method f❑vlud Rotary 04ir Rotary D Auger D Cable Tool D Push Point ❑ Other <br /> Proposed Well Depth 45 ft Excavation in diameter D Open Bottom ravel Pack/Gravel Size in diameter <br /> D Conductor Casing n/a in diameter / Conductor Casing Depth n/a ft <br /> Well Casing Diameter c l Thir�Icness/Gauge/ASTM Schad PVC Sch 60 F-1SteelD Plastic D Stainless Steel 13ther <br /> Grout Seal Depth: It ✓3 Neat Cement(94 Ib bag/5-10 gal water) D Sand Cement sack mW7 gal water <br /> D Bentonite I(.20%solids) D Other <br /> Grout Placement Method itec rumped n Free Fall ❑Other Tremmie D Retardant/Accelerator(name) <br /> PEDESTAL Installed By E]Driller D Pump Contractor LZJ Other M-u—nt <br /> D Concrete Pedestal❑Dimensions:Width ft Length ft Thick in D Christy Box D Stove Pipe <br /> PUMP D SubmersibleEl Turbine D Other N/A HP N/A Pump Set N/A ft Standing Water Level N/A 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 ORDI CES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIV WIT THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS,COMPEN TION AWS. <br /> MINIMU 48 UR ADV�ry/��'�7+'E OTICE REQUIRED FO I SPECT N PLEASE CALL(209)953-7697 <br /> SIGNED /G� �— T / DATE �f <br /> S E E P L A N S F O R D E T A I L S <br /> MENT <br /> EIVED <br /> 4 2019 <br /> UIN COUNTY <br /> cN TH pONMENTAL <br /> EPA TMENT US ONLY (,IEPARTMENT <br /> t �— <br /> Application Accepted By Date AretWA <br /> Employee ID# <br /> Grout Inspection By Date Z // PECIAL Well <br /> Permit <br /> Pump Inspection By Date IVER ReC@Ived /l <br /> Soil Boring Insp c.on By Date Constructed Well Depth ft <br /> COMMENTS �9( <br /> PE SC Received CheckJQ Amount DaPermit/ # Well ID# <br /> Codes �tq B ` Remitte e Service Re uest# <br /> 1 0�/ 1 <br /> Egt <br /> EHD 43.06 revised 4/14/18 WELL/PUMP PERMIT <br />