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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 -(2a9)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES'I YEAR FROM DATE ISSUED <br /> N <br /> Joe ADDRESS 1315 W Swain Rd,Stockton (skaal lrtf nt of this property adds see maps heroes) Cm7ZW CA 95207 <br /> Milchler Ave <br /> CROSS STREET_ APN 097-290-16 PARCEL SIZE- f• LAND USE APPLICATION# <br /> OWNER NAME City Of Stockton PHONE <br /> OWNER ADDRESS City Hall,425 N.Ef Dorado St. CITY/STATE/Ztp Stockton,CA 95202 i <br /> CONTRACTOR Underground Construction Co, PHONE 707-741-1761 <br /> CONTRACTOR ADDRESS 5145 Industrial Way CITYISTATEIZIP Benicia,CA 94510 <br /> SUBCONTRACTOR Corrpro Companies Inc. PHONE 510-509-499 <br /> t <br /> SUBCONTRACTOR ADDRESS 2815c Bar ington Court CITYISTATEIZJP Hayward,CA 94545 <br /> i <br /> LICENSE VC-57 U C-61 ❑D-09 Other NUMBER 764878 EXPIRATION DATE <br /> I <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)❑Dibromochloropropane(4392)u Arsenic(4393) <br /> INTENDED USE D DOmesliCJPdVate D Irrigalion/Agricultural n Industrial rl Water Quality Monilortng U Sell Sampling/Characterization <br /> ❑Public Water System <br /> If different from Omer: Warer System Nemo Cenlact Name or Phone Number <br /> TYPE OF WORK ❑New Well D Replacement Well U Well AlteratlonlModification D Other Cathodic Protection <br /> U Monitoring Wells) #of wells U Sall Boring(s) #of 1h rin9' 0 Geotechnical N of berms, <br /> U Out-Of-Service Well 0 Out-Of-Service Well Renewal 0 Cross-Connection Repair <br /> D NewPump u Pump Replacement U Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method S/Mud Rotary U Air Rotary U Auger U Cable Tool U Push Point D Other <br /> Proposed Well Depth 200 It Excavation 6„ In diameter U Open Bottom Gravel Pack/Gravel Size in diameter <br /> D Conductor Casing no"I" in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_In Thickness/Gauge/ASTM Schad ❑Steel O Plastic L)Stainless Steel D Other <br /> Grout Seal Depth 71lrr R ' Neat Cement(94/b bag6-10 gat water) U Sand Cement sack mix/7 gal water <br /> 3entonila(20%solids) U Other <br /> Grout Placement Method D Pumped D Free Fall 0 Other D Retardant/Accelerator(name) <br /> PEDESTAL Installed By U Driller 0 Pump Contractor U Other <br /> D Concrete Pedestal DDimenslons:Width ft Length ft Thick In U Christy Box U Stove Pipe <br /> E._-P D Submersibteu Turbine U Other HP Pump Set ft Standing Water Level ft 1 <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT ND ACTIVE WITH AE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL i <br /> WORKERS�CZMPENSATION 1-404S.MIN�MUM:g8 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS•PLEASE CALL(209)943'7pst. <br /> SIGNED �{ TITLE ( • . DATE I , <br /> t Y 1 <br /> r A L"1-1 l <br /> N,o�aU1 N 1 <br /> N�IINA DEPARTMENT USE NLY <br /> Application Accepted By Date Area Employee ID# rf <br /> Grout Inspection By Dale ❑ SPECIAL Well Permit <br /> Pump Inspection By Dale 11 WAIVER Received <br /> Soil Baring Inspection By Dale Constructed Well Depth h <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Perm(U Invoice# Well ID# <br /> Codes Info Cash Remitted Service Re uest0 <br /> EHD 43-06 r.NI d4114116 Q WELIRUMPPERMR <br />