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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)4683420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS West Ln Calaveras North Pump Station CITy/Zlp Stockton 95209 <br /> D <br /> CROSS STREET West Ln.&Calveras River Bike Ph APN 10437009 PARCEL SIZE 0.29 acres LAND USE APPLICATION# o <br /> A <br /> m <br /> OWNER NAME City of Stockton Municipal Utility Dept. Job#M16010 PHONE 209-937-8700 <br /> OWNER ADDRESS 2500 Navy Drive CITY/STATEIZIP Stockton CA 95206 <br /> CONTRACTOR Fanvest Corrosion Control PHONE 510-952-6256 <br /> CONTRACTOR ADDRESS 2223 Commerce Place CITY/STATE/ZIP Hayward CA 94545 <br /> SUBCONTRACTOR n/a PHONE n/a <br /> SUBCONTRACTOR ADDRESS n/a CITY/STATEMI,n/a <br /> LICENSE ZC-57 OC-61 E]D-09 Other NUMBER 248232 EXPIRATION DATE 12-31-2019 <br /> DOMESTIC WELL SAMPLING:0 General Mineral/Coliform Bacteria(4391)0 Dibromochloropropane(4392)0 Arsenic(4393) <br /> INTENDED USE Domestic/Private Innigation/Agricultural Ljndustrial 0 Water Quality Monitoring D Soil Sampling/Characterization <br /> Public Water System <br /> If diRerent from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well 17 Replacement Well 0 Well Alteration/Modification ✓ Other <br /> 0 Monitoring Well(s) #of wells oil Boring(s) #of borings ❑Geotechnical #of bKngs <br /> 0 Out-Of-Service Well ri Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> 0 New Pump ❑Pump Replacement Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ZvIud Rotary DAir Rotary ❑Auger 0 Cable Tool ❑Push Point El Other <br /> Proposed Well Depth 45 ft Excavation in diameter ❑Open Bottom ravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing nla in diameter / Conductor Casing Depth n/a ft <br /> Well Casing Diameter c I Thic ness/Gauge/ASTM Sched PVC Sch 80 Steel 11 Plastic ❑Stainless Steel �ther <br /> Grout Seal Depth �t ✓❑Neat Cement(94 Ib bag/5-10 gal water) ❑Sand Cement sack mixn gal water <br /> ❑Bentonite(20%solids) 0 Other <br /> Grout Placement Method�umped 0 Free Fall ❑Other Tremmie ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By QDriller ❑Pump Contractor ✓j Other Nenumnl <br /> ❑Concrete Pedestal❑Dimensions:Width ft Length ft Thick in ❑Christy Box 0 Stove Pipe <br /> PUMP u Submersible_Turbine ❑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 ORD CES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTT WIT THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS-GOMPEN TION AWS. <br /> INIMU 48 UR ADV�ery/ E OTICE REQUIRED IF I SPECT ON PLEASE CALL(209)953-7697 <br /> SIGNED IV DATE <br /> S E E P L A N S F O R D E T A I L S <br /> MENT <br /> EIVED <br /> '+ 2019 <br /> FEE E -T-FTI UIN COUNTY <br /> cWTH ONMENTAL <br /> EPA TMENT US ONLY PARTMENT <br /> Application Accepted By DateAkhArea Employee ID# <br /> Grout Inspection By Date SPECIAL W@II P@rmit /J <br /> Pump Inspection By Date WAIVER R@C@IV@d ` <br /> Soil Boring Insp 'an By Date Constructed Well Depth ft <br /> COMMENTS `ry <br /> PE SC Received Ch Amount Dae Permit/ Invoice# Well ID# <br /> Codes Irr�r} B ` D Remitted— ervice Re uest# <br /> I ( 1 <br /> 91 <br /> EHD 43.06 revised 4/14118 WELL/PUMP PERMIT <br />