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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'I YEAR FROM DATE ISSUED <br /> LA <br /> JOB ADDRESS Royal Oaks Pump Station a CITy21P Stockton 95209 M <br /> D <br /> CROSS STREET Royal Oaks Rd.8 Davis Rd. APN 07222052 PARCEL SIZE 3.57 acres LAND USE APPLICATION# z <br /> m <br /> OWNER NAME City of Stockton Municipal Utility Dept. Job#M16010 PHONE 209-937-8700 y <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/LP Hayward CA 94545 <br /> SUBCONTRACTOR n/a PHONE n/a <br /> SUBCONTRACTOR ADDRESS n/a CITY/STATE/ZIP n/a <br /> LICENSE WIC-57 [:]C-61 [—]D-09 Other NUMBER 248232 EXPIRATION DATE 12-31-2019 <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)D Dibromochloropropane(4392)Cl Arsenic(4393) <br /> INTENDED USE DomesticlPrivate 0"gation/Agricultural Ljndustrial D Water Quality Monitoring Soil Sampling/Characterization <br /> ri Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK W/New Well D Replacement Well ❑Well Alteration/Modification ✓ Other <br /> 0 Monitoring Well(s) #of wells oil Boring(s) #of borings D Geotechnical or rings <br /> D Out-Of-Service Well 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 ✓Aud Rotary I]Air Rotary D Auger D Cable Tool D Push Point ❑ Other <br /> Proposed Well Depth 45 ft Excavation in diameter D Open Bottom Lfiravel Pack/Gravel Size in diameter <br /> D Conductor Casing Na in diameter / Conductor Casing Depth n/a ft <br /> Well Casing Diameter .6 i Th''ckness/Gauge/ASTM Schad PVC Sch 80 Steel D Plastic D Stainless Steel �ther <br /> Grout Seal Depth��ft [ENeat Cement(94 lb bag/5-10 gal water) D Sand Cement sack mixf7 gal water <br /> D Bentonite(2 %solids) D Other <br /> Grout Placement Method[✓�umped D Free Fall D Other Tremmie ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ODriller D Pump Contractor M Other--n, <br /> E Concrete Pedestal Dimensions:Width ft Length ft Thick in D Christy Box D Stove Pipe <br /> PUMP D Submersible Turbine Other N/A HP WA Pump Set NIA it Standing Water Level wA 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 S, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTT ITH HE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENS ON L <br /> INIMU 48 H ADVANCE PIOTICE REQUIRED FOR I PECTIONS;, LEASE CALL(209)953-7697 <br /> SIGNED TITL /' ' .�ISATE <br /> S E E P L A N S F OIRI D E T A I L S <br /> MENT <br /> EIVED <br /> 4 20)9 <br /> IN COUNTY <br /> ��#-44TF--- MENTAL <br /> PARTMENT <br /> P,A T M E N T U E N L Y <br /> Application Accepted By Date Area Employee ID#� <br /> Grout Inspection By Date SPECIAL Well Permit o li ' <br /> Pump Inspection By Date WAIVER Received �l <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> CO MENTS <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Cash Remitt#A Service Request# <br /> i ! <br /> EHD 4348 revised 4/14/18 WELL/PUMP PERMR <br />