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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HA2ELTON 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 Arch Road Industrial Park Pump Station CtTYrljp Stockton 95215 <br /> D <br /> CROSS STREET Gold River Ln.&Arkansas PI. APN 17926032 PARCEL SIZE 6.10 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/STATEILP Stockton CA 95206 <br /> CONTRACTOR Farwest Corrosion Control PHONE 510-952-6256 <br /> CONTRACTOR ADDRESS 2223 Commerce Place CITYISTATEILP Hayward CA 94545 <br /> SUBCONTRACTOR n/a PHONE Na <br /> SUBCONTRACTOR ADDRESS We CITY/STATE/ZIP We <br /> LICENSE FZIC-57 0 C-61 OD-09 Other NUMBER 248232 EXPIRATION DATE 12-31-2019 <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)❑Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE Domestic/Private 1:7gation/Agricultural ndustrial 0 Water Quality Monitoring 0 Soil Sampling/Characterization <br /> Public Water SysteLLmJJ <br /> If dlHerent from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ZNew Well 11 Replacement Well D Well Alteration/Modification ✓ Other <br /> 0 Monitoring Well(s) #of wells Soil Bofing(s) #of borings D Geotechnical #o bodngs <br /> 0 Out-Of-Service Well 0 Out-Of-Service Well Renewal D Cross-Connection Repair <br /> D New Pump ❑Pump Replacement 0 Pump Repair D Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ✓Qvtud 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 /> Conductor Casing nla in diameter / Conductor Casing De th n/a ft <br /> Well Casing Diameter 4 in Thickness/Gauge/ASTM Schad PVC Son 80 Steel D Plastic D Stainless Steel Dther <br /> i <br /> Grout Seal Depth ft QNeat Cement(94 lb bag/5-10 gal water) D Sand Cement sack mix/7 gal water <br /> []Bentonite(_20%solids) El Other <br /> Grout Placement Method)�terumped ❑Free Fall Other Tremmie ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller ❑Pump Contractor LILJ Other^+o^ nt <br /> 0 Concrete Pedestal DDlmensions:Width it Length ft Thick in D Christy Box D Stove Pipe <br /> PUMP ❑Submersible[]Turbine 0 Other N/A HP NIA Pump Set NIA it 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 ORDINAN ATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE W THE ALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKER COMPENSAT LAWS. <br /> INIMUM HOUR VA %�J� IQF RRE-QUUIIR.EED.-FOR�I�SPECTIO S�E7ASP (209),9 3-76Q�SIGNED - TITL pTE <br /> S E E P L A N S F O R D E T A I L S <br /> io <br /> H <br /> D At M E N T U E O LY <br /> Application Accepted By Date Area Employee ID#� <br /> Grout Inspection By Date SPECIAL W@II Permit r"t <br /> Pump Inspection By Date iWAIVER R@C@IVed r <br /> Soil Boring 13Ann By 1 1- Date 0' Constructed Well Depth ft <br /> CO G NTS O Q <br /> A:01 t6 <br /> e <br /> PE Sc Received Check#/ Amount Permit] <br /> Codes Irlfo B 1 Cash IfRemitted Date Service Re uest# Invoice# WeIIID# u 'V <br /> Sw i <br /> Q0 <br /> "41 _p�wl <br /> EHD 43-06 revised 4114118 / 1_ -r J_— 9 COIN )99 2, WELL(PUMP PERMIT <br />