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WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED rn JOB ADDRESS Fort Donelson&14 Mile Slough CITy/ZIP Stockton 95209 in D CROSS STREET Fort Donelson Rd. Apll 09843036 PARCEL SIZE 0.17 acres LAND USE APPLICATION# O z m OWNER NAME City of Stockton Municipal Utility Dept. Job#M1601O PHONE 209-937-8700 w OWNER ADDRESS 2500 Navy Drive CITY/STATE/ZIP Stockton CA 95206 CONTRACTOR Farwest Corrosion Control PHONE 510-952-6256 CONTRACTOR ADDRESS 2223 Commerce Place CITY/STATE/ZIP Hayward CA 94545 SUBCONTRACTOR n/a PHONE n/a SUBCONTRACTOR ADDRESS n/a CITY/STATE/ZIP n/a LICENSE ZC-57 OC-61 [::]D-09 Other NUMBER 248232 EXPIRATION DATE 12-31-2019 DOMESTIC WELL SAMPLING:C General Mineral/Coliform Bacteria(4391)o Dibromochloropropane(4392)0 Arsenic(4393) INTENDED USE Domestic/Private LL[ -Tigation/Agricultural ndustrial D Water Quality Monitoring ❑Soil Sampling/Characterization Public Water SystemJJ If difleren[from Owner. Water System Name Contact Name or Phone Number TYPE OF WORK 1/New Well ElReplacement Well n Well Alteration/Modification ✓ Other 0 Monitoring Well(s) #of wells Soil Boring(s) #of borings ❑Geotechnical #of borings ❑Out-Of-Service Well 0 Out-Of-Service Well Renewal ❑Cross-Connection Repair D New Pump ❑Pump Replacement 0 Pump Repair ❑Raise Well Casing WELL CONSTRUCTION Drilling Method ZMud Rotary Q4ir Rotary 0 Auger ❑Cable Tool 0 Push Point ❑ Other Proposed Well Depth 45 ft Excavation in diameter D Open Bottom ravel Pack/Gravel Size in diameter 0 Conductor Casing n/a in diameter / Conductor Casing Depth n/a It Well Casing Diameter c i TDickness/Gauge/ASTM Schad PVC Sch 60 Steel ❑Plastic D Stainless Steel [])ther Grout Seal Depth ft ❑✓ Neat Cement(94 Ib bag/5-10 gal water) D Sand Cement sack mixl7 gal water ❑Bentonite(20%solids) ❑Other Grout Placement Method ✓[ umped ❑Free Fall ❑Other Tremmie ❑Retardant/Accelerator(name) PEDESTAL Installed By [Z]Driller 0 Pump Contractor [.!Lj Other Mon-1 ❑Concrete Pedestal❑Dimensions:Width ft Length ft Thick in 0 Christy Box D Stove Pipe PUMP ❑SubmersibleD Turbine ❑Other N/A HP N/A Pump Set N/A ft Standing Water Level N/A ft I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCE STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT ANLACTIVE WI THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COATI LAWS.MINI OU DVANCE TIC REQUIR R SPEC N -PLEASE CALL(209) 3-7697 SIGNED TI DATE S E El P L A N S F O 1 R D E T A I L S ENT IVE® IN COUN Y �At1ENT�kL PF�EtT TENT DE ARTMENT U 'E 0 LY Application Accepted By Dates �+ Area Employee IDI SN Grout Inspection By 40 Date PECIAL Well Permit OKor& Mk/r# Pump Inspection B Date ❑ WAIVER Received Soil Boring Inspe tion By Dat Fonstruct d Well Dep h ft CO ENTS 1; � O H P S 1,% PE SC Received ecI Amount Da Permit/ Invoice# I # Codes Info B Remitted ervice a uest# I t Z EHD 43-06 revised 4/14/18 WELL/PUMP PERMrr