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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 FQRIU5PECTIONIS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Quail Lakes Alexandria 8 5 Mile Slough) L r m <br /> JOB ADDRESS ( 9 ) rj"rCITY/ZIP Stockton95206 m <br /> D <br /> CROSS STREET Alexandria PI APN 11206067 PARCEL SIZE 0.33 acres LAND USE APPLICATION# o <br /> m <br /> OWNER NAME City of Stockton Municipal Utility Dept. Jot)#M16010 PHONE 209-937-8700 N <br /> OWNER ADDRESS 25M 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/ZIP Hayward CA 94545 <br /> SUBCONTRACTOR n/a PHONE We <br /> SUBCONTRACTOR ADDRESS nla CITY/STATE/ZIP We <br /> LICENSE F✓ C-57 0 C-61 [:]D-09 Other NUMBER 248232 EXPIRATION DATE 12-31-2019 <br /> DOMESTIC WELL SAMPLING:-General Mineral/Coliform Bacteria(4391)C Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private I--'trigation/Agricultural ndustrial --Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water Systemm�J <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK I'llNew Well Replacement Well --Well Alteration/Modification ✓ Other <br /> 0MonitoringWell(s) #of wells[:joil Boring(s) #ofbonngs = Geotechnical #ofbonngs <br /> - Out-Of-Service Well -Out-Of-Service Well Renewal = Cross-Connection Repair <br /> - New Pum - Pump Replacement - Pump Repair = Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ✓Aud Rotary E34ir Rotary E Auger E Cable Tool - Push Point ❑ Other <br /> Proposed Well Depth 45 ft Excavation in diameter -Open Bottom ravel Pack/Gravel Size in diameter <br /> -Conductor Casing n/a in diameter / Conductor Casing th n/a ft <br /> Well Casing Diameter L De in Thickness/Gauge/ASTM Sched PVC Sch 80 Steel E Plastic -Stainless Steel [])ther <br /> i <br /> Grout Seal Depth ft [Z]Neat Cement(94 lb bag/5-10 gal water) E Sand Cement sack mix/7 gal water <br /> - <br /> Bentonite((2 %solids) =Other <br /> Grout Placement Methodr+ rumped =Free Fall =Other Tremmie Retardant/Accelerator(name) <br /> PEDESTAL Installed By [DDriller = Pump Contractor LLJ Other <br /> - Concrete Pedestal=DimensionsWidth ft Length ft Thick in - Christy Box :.Stove Pipe <br /> PUMP =Submersible=Turbine E Other NA HP N/A Pump Set NIA ft Standing Water Level MA It <br /> I HEREBY CERTIFY THAT I..tIQVE 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 AND ACTIVE WITH,THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION WS. <br /> MI QIMU t8 R A V N/(7✓+�JN TICE REQUIRED FORASPECT NS PLEASE CALL(209)953-76 7 SIGNED Ti`-� ,•4 �— DATE <br /> S E E P L A N S F O R DIE T A I L S <br /> T <br /> D <br /> c19 <br /> uNTY yff MIT <br /> AL <br /> ENT <br /> EPARTMENT USE O LY <br /> I j-•�/ < 4 <br /> Application Accepted By rV '� Date 1 Area Employee IDS# �l AA' I`l-C'4—�,/ <br /> Grout Inspection By Date / SPECIAL Well Permit <br /> Pump Inspection By Date _ WAIVER Received I <br /> Soil Boring In cti in ByDate Constructed jell D pth <br /> COMMENTS C r Y w a/ �� i i^ I✓1 0(4 - GIDhi�n <br /> le" <br /> PE SC Received ec 'mount Date PermiU Invoice# Well ID# <br /> Codes Ino B Remitted Service Re uest# �/ <br /> D -`..- <br /> EHD 43-06—i-,1411141118 WELL/PUMP PERMIT <br />