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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 /> to <br /> JOB ADDRESS 8th St.San Joaquin River Pump Station CITY/ZIP Stockton 95206 m <br /> D <br /> CROSS STREET E San Joaquin Rvr Levee Rd. APN 16307025 PARCEL SIZE 0.98 acres LAND USE APPLICATION# o <br /> m <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/STATE2IP Stockton CA 95206 <br /> CONTRACTOR Fanvest 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 CITYISTATE/ZIP n/a <br /> LICENSE IZIC-57 ❑C-61 [:]D-09 Other NUMBER 248232 EXPIRATION DATE 12-31-2019 <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(439 1)D Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE Domestic/Private r—`Tgation/Agricultural Ljndustrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> Public Water System <br /> If different from mer: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK zNew Well D Replacement Well c Well Alteration/Modification ✓ Other <br /> ❑Monitoring Well(s) #of wells Soil Boring(s) #of borings []Geotechnical or borings <br /> 0 Out-Of-Service Well E Out-Of-Service Well Renewal D Cross-Connection Repair <br /> D New Pump []Pump Replacement E Pump Repair D Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method OVlud Rotary E]Nr Rotary ❑Auger D Cable Tool D Push Point ❑ Other <br /> Proposed Well Depth 45 ft Excavation in diameter []Open Bottom ravel Pack/Gravel Size in diameter <br /> D Conductor Casing n/a in diameter / Conductor Casing De th n/a ft <br /> Well Casing Diameter L in Ti ckness/Gauge/ASTM Schad PVC Sch 80 Steel D Plastic D Stainless Steel 13)ther <br /> G rout Seal Depth ft ✓]Neat Cement(94/b bagIS-10 gal water) ❑Sand Cement sack mix/7 gal water <br /> o Bentonite <br /> �tt(_2 ,6 solids) []Other <br /> Grout Placement Method _ umped ❑Free Fall E Other Tremmie []Retardant/-Accelerator(name) <br /> PEDESTAL Installed By Driller D Pump Contractor LZ_j Other Monomem <br /> D Concrete Pedestal[]Dimensions:Width ft Length ft Thick in D Christy Box []Stove Pipe <br /> PUMP D Submersible[]Turbine ❑Other N/A Hp N/A Pump Set NIA ft Standing Water LevelN/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 O NCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT ANDA E WI H THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMP NSATIO LAWS. <br /> ' MINI M 48 UR ADVAN�ICE REQUIRED F PECT4 NS PLEASE CALL(209)2§3-7697 <br /> SIGNED •TIT A <br /> S E E P L A N S F O R D HIT A I L S <br /> ENT <br /> IVE® <br /> 4L'd9 <br /> IN COUNTY <br /> ie9CNTAL i <br /> PT M E N T S E Q N L Y HEALTH DEPARTMENT <br /> Application Accepted By f ' Date !' Area_l Employee ID#�l <br /> Grout Inspection By Date ^ 0X SPECIAL Well Permit PC4L <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Const uct Well Depth <br /> COMMENTS <br /> PE SC Received Checp to Permit/ Invoice# Well ID# <br /> CodesIf B sh emitted ervice e u L# <br /> wt)s 13715' WV DOM, <br /> EHD 43-06 revised 4/14/18 WELL/PUMP PERMIT <br />