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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 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS Plymouth Rd 8 5 Mile Creek Pump Station/707 y CITY/ZIP N <br /> I Stockton 95206 m <br /> D <br /> CROSS STREET Plymouth Rd APN 09756025 PARCEL SIZE 0.25 acres LAND USE APPLICATION# o <br /> A <br /> m <br /> OWNER NAME City of Stockton Municipal Utility Dept. Job#M16010 PHONE 209-937-8700 m <br /> OWNER ADDRESS 2500 Navy Drive CITYISTATE/ZJP Stockton CA 95206 <br /> CONTRACTOR Famest 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 CITYISTATE/ZIP n/a <br /> LICENSE ZC-57 OC-61 [—]D-09 Other NUMBER 248232 EXPIRATION DATE 12-31-2019 <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391)i 1 Dibromochloropropane(4392)1 I Arsenic(4393) <br /> INTENDED USE Domestic/Private E' rigation/Agricultural ndustrial "Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water SysteL_m_JI <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ZNewWeII i-Replacement Well ❑Well Alteration/Modification ✓ Other <br /> ED Monitoring Well(s) #of wells oil Boring(s) #of borings Geotechnical #of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pum Pump Replacement L Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ZIud Rotary Q4ir Rotary i Auger i 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 We in diameter / Conductor Casing Depth We ft <br /> Well Casing Diameter L I Thickness/Gauge/ASTM Sched PVC Sch 80 ❑Steel _ Plastic Stainless Steel �ther <br /> Grout Seal Depth ft ✓DNeat Cement(94 lb bag/5-10 gal water) Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement MethodEkmped I Free Fall .Other Tremmie i Retardant/Accelerator(name) <br /> PEDESTAL Installed By ODriller -: Pump Contractor L.Lj Other Menvment <br /> Concrete Pedestal:-:Dimensions:Width ft Length ft Thick in Christy Box Stove Pipe <br /> PUMP 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 ORDINA STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE H T CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSA N LAW . <br /> IMUM HO ADVAN � TIIV REQUIRED FOR, N ECTIQ S- EASE CALL(209)9�8-769 <br /> SIGNED V TITLE DATE / <br /> S E El P I L I A N S F O R D E T A I L S <br /> T <br /> AR YM ENT SE ONLY <br /> C <br /> Application Accepted By Date Area Employee ID# VV— <br /> Grout Inspection By Date SPECIAL Well Permits /N. , Tfj/ <br /> Pump Inspection By Date WAIVER Received <br /> Soil Baring Inspection By Date Constructed Well Depth ft <br /> COMMENTS ���V <br /> O <br /> PE Sc Received Check#/ Amount Permit/ <br /> Codes fo B Cash emitted Date Service Re uest# Invoice# Well ID# <br /> 'WV-17V— U5N4-u& WP6U5107 <br /> EHD 43-06 revised 4114/18 ^ 4. egg$y g g 2 WELL/PUMP PERMIT <br />