Laserfiche WebLink
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 /> U1 <br /> JOB ADDRESS Charter Way Industrial Park Pump Station(near 1627 Army Ct.) CITY/ZIP Stockton 95206 <br /> D <br /> CROSS STREET Charter Hwy APN 16334004 PARCEL SIZE 2.07 acres LAND USE APPLICATION# <br /> m <br /> OWNER NAME City of Stockton Municipal Utility Dept. Job#M16010 PHONE 209-937-8700 m <br /> OWNER ADDRESS 2500 Navy Drive CITYISTATEZP Stockton CA 95206 <br /> CONTRACTOR Farwest Corrosion Control PHONE 510-952-6256 <br /> CONTRACTOR ADDRESS 2223 Commerce Place CITYISTATEZP Hayward CA 94545 <br /> SUBCONTRACTOR We PHONE n/a <br /> SUBCONTRACTOR ADDRESS n/a CITY/STATE/ZIP n/a <br /> LICENSE IZIC-57 OC-61 [:]D-09 Other NUMBER 248232 EXPIRATION DATE 12-31-2019 <br /> DOMESTIC WELL SAMPLING:C General Mineral/Coliform Bacteria(4391)0 Dibromochloropropane(4392)Ll Arsenic(4393) <br /> INTENDED USE Domestic/Private gation/Agricultural Ljndustrial D Water Quality Monitoring 0 Soil Sampling/Characterization <br /> Public Water Syste <br /> II different from Owner. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK Z New Well D Replacement Well 0 Well Alteration/Modification %/ Other Cathodic Protection <br /> D Monitoring Well(s) #of wells Soil Borings) #of borings ❑Geotechnical #of borings <br /> 0 Out-Of-Service Well D Out-Of-Service Well Renewal D Cross-Connection Repair <br /> D New Pump D Pump Replacement D Pump Repair [I Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ZAud Rotary 134ir Rotary D Auger D Cable Tool D Push Point F] Other <br /> Proposed Well Depth 45 ft Excavation in diameter D Open Bottom ravel Pack/Gravel Size in diameter <br /> D Conductor Casing We in diameter / Conductor Casing De th n/a ft <br /> Well Casing Diameter c in Thickness/Gauge/ASTM Sched PVC Sch 60 Steel D Plastic D Stainless Steel 13ther <br /> Grout Seal Depthrft ✓]Neat Cement(94 Ib bag/5-10 gal water) D Sand Cement sack mix/7 gal water <br /> ❑Bentonite(20%solids) D Other <br /> Grout Placement Method�pumped 0 Free Fall ❑Other Tremmie D Retardant/Accelerator(name) <br /> PEDESTAL Installed By QDriller - Pump Contractor LZJ Other Monument <br /> D Concrete Pedestal El Dimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP ❑Submersible❑Turbine D Other NIA HP NIA Pump Set NIA ft Standing Water Level NIA 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 OR STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND AC WITH E CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMP SATION LAW . <br /> MIN M 48 HOU DVA OT E REQUIRED FOR SPE�/ LEASE CALL(209),g3-7697 <br /> SIGNED // <br /> �WDAXE <br /> S E E P L A N S F C R D E T A I L S <br /> NT <br /> ED <br /> 099 <br /> UNTY <br /> TAL <br /> PA TMENT LIS E O t�LY -�EALT)") EPAR ENT <br /> Application Accepted By Date Area Employee ID <br /> Grout Inspection By Date -jLflSPECIAL Well Permit F19Z <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft r <br /> COMMENTS 1,b [h /��/r <br /> PE SC Received Check#/ Amount Permit/Codes fo B Cash emitted Date S i e uest# Invoice# WeIIID# <br /> 7-S <br /> EHD 43-06 revised 4n411e WELL/PUMP PERMIT <br />