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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 /> w <br /> JOB ADDRESS Fort Donelson&14 Mile Slough CITY/ZIP Stockton 95209 m <br /> D <br /> CROSS STREET Fort Donelson Rd. APN 09843036 PARCEL SIZE 0.17 acres LAND USE APPLICATION# z <br /> m <br /> OWNER NAME City of Stockton Municipal Utility Dept. Job#M16010 PHONE 209-937-8700 m <br /> OWNER ADDRESS 2500 Navy Drive CITY/STATEZP Stockton CA 95206 <br /> CONTRACTOR Farwest Corrosion Control PHONE 510-952-6256 <br /> CONTRACTOR ADDRESS 2223 Commerce Place CITY/STATE/ZJP Hayward CA 94545 <br /> SUBCONTRACTOR n/a PHONE n/a <br /> SUBCONTRACTOR ADDRESS nla CITY/STATE/71P n/a <br /> LICENSE FZIC-57 0C-61 [—]D-09 Other NUMBER 248232 EXPIRATION DATE 1231-2019 <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)0 Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE Domestic/Privategation/Agricultural LjIndusbial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> Public Water Sy 9 <br /> If different hom Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK V- New Well ❑Replacement Well ❑Well AlterationlModification ✓ Other Cathodic Pro ection X <br /> EJ Monitoring Well(s) #of wells Soil Boring(s) #of bodngs []Geotechnical #of borings <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ❑New Pump ❑Pump Replacement ❑Pump Repair D Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method❑vlud Rotary r wir Rotary ❑Auger ❑Cable Tool D Push Point 1:1 Other <br /> Proposed Well Depth 45 ft Excavation in diameter ❑Open Bottom Javel Pack/Gravel Size in diameter <br /> []Conductor Casing n/a in diameter / Conductor Casing De th n/a ft <br /> Well Casing Diameter c I Thickness/Gauge/ASTM Schad PVC Sch e6 IlSteel ❑Plastic ❑Stainless Steel []Dther <br /> Grout Seal Depth ft ✓]Neat Cement(94/b bag/5-10 gal water) ❑Sand Cement sack mixl7 gal water <br /> 0 Bentonite(2�6%solids) El Other <br /> Grout Placement MethodLrumped Free Fall ❑Other Tremmie ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By E]Driller ❑Pump Contractor L✓j Other Monvmem <br /> ❑Concrete Pedestal❑Dimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP ❑Submersible[]Turbine ❑Other N/A HP NIA Pump Set N/A 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 ORDINANCES. STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WI THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS CO PENSATI LAWS <br /> MINI M4 <br /> VC kLL(209) 53 <br /> 7/ -7697 <br /> SIGNED DATE <br /> IIIA IIII 1111 11111 . 1111 111 11111 <br /> S E E P L A N S IF O R D E T A I L S <br /> ENT <br /> IVE® <br /> IN COUNTY <br /> Ji1AE JT,"%L <br /> r <br /> PARTMENT <br /> DE ARTMENT USE OkJLY <br /> Application Accepted By Date 3 4 AreaePECEIALRWelEl <br /> mployee ID# Sv <br /> Grout Inspection By Date I Permit O k �tICI-r# <br /> Pump Inspection B Date eCeived <br /> Soil Baring Inspection By Dat Construct d Well Dep h ft <br /> CO MENTS r WJ e 1 O <br /> � J1((j(A1V <br /> PE SC Received eck# Amount Da Permit/ Invoice# <br /> Codes Info B Remitted ervice a nest# <br /> I <br /> Z <br /> EHD 43-06 reAsed 4114118 WELL(PUMP PERMrr <br />