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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 /> rn <br /> JOB ADDRESS Grupe Business Park Pump Station CITy21P Stockton 95209 <br /> D <br /> CROSS STREET Val Dervin Pkwy&Frank W Cir. APN 19342007 PARCEL SIZE 0.73""'LAND USE APPLICATION# <br /> m <br /> OWNER NAME City of Stockton Municipal Utility Dept. Job#M16010 PHONE 209-937-8700 y <br /> OWNER ADDRESS 2500 Navy Drive CITY/STATE/7JP Stockton CA 95206 <br /> CONTRACTOR Farwest Corrosion Control PHONE 510-952-6256 <br /> CONTRACTOR ADDRESS 2223 Commerce Place CITY/STATEZP Hayward CA 94545 <br /> SUBCONTRACTOR n/a PHONE Na <br /> SUBCONTRACTOR ADDRESS We CITY/STATE/7jp n/a <br /> LICENSE WIC-57 ❑C-61 E]D-09 00ther 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 [nTigation/Agricultural ndustrial 0 Water Quality Monitoring 0 Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORKV/New Well 0 Replacement Well D Well Alteration/Modification ✓ Other <br /> ❑Monitoring Well(S) #of wells Soil Bodng(s) #of bodngs D Geotechnical #of borings <br /> 0 Out-Of-Service Well 0 Out-Of-Service Well Renewal 0 Cross-Connection Repair <br /> D New Pum 0 Pump Replacement 0 Pump Repair 0 Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Ztud Rotary i wir Rotary 0 Auger 0 Cable Tool 0 Push Point ❑ Other <br /> Proposed Well Depth 45 ft Excavation in diameter 0 Open Bottom ravel Pack/Gravel Size in diameter <br /> 0 Conductor Casing n/a in diameter / Conductor Casing Depth n/a ft <br /> Well Casing Diameter Wit,in Thickness/Gauge/ASTM Sched PVC sch ao Steel 0 Plastic 0 Stainless Steel �ther <br /> Grout Seal Depth -fif 1 I�ft [Z]Neat Cement(94 Ib bag/5-10 gal water) D Sand Cement sack mix/7 gal water <br /> 0 Bentonitee((2 °h'Sololids) 0 Other <br /> Grout Placement Method[Umped 0 Free Fall 0 Other Tremmie 0 Retardant/Accelerator(name) <br /> PEDESTAL Installed By E]Driller C Pump Contractor LL1 Other Monumn/ <br /> Concrete Pedestal FiDimensions:Width ft Length ft Thick in D Christy Box 0 Stove Pipe <br /> PUMP Submersible.-Turbine 0 Other N/A HP N/A Pump Set N/A ft Standing Water Level NrA 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 WIT. CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATIO, LAWS. <br /> IV IMUM 48 WOUR VANCE NOTI E REQUIRED R I ECTIO -P EASE CALV(209)9 3-7§97 <br /> /� i--� <br /> SIGNED TITLE 4' ' _DATE <br /> S E E P L A N S F O R D E T A I L S <br /> op�P <br /> R T M E N T UIS E O LY <br /> Application Accepted By Date 1 Area Employee ID#� f� <br /> Grout Inspection By Date SPECIAL Well Permit_ M_ <br /> Pump Inspection By Date I WAIVER Received <br /> Soil Boring Inspection By ate 7 11 Constructed Well Depth ft <br /> CO MENTS All A17;1 <br /> r i <br /> PE SC Received Check# Amount Dat Permit/ Invoice# Well ID# <br /> Codes Info B Cash Remitted rvic u s # a <br /> N <br /> EHD 43-06 revised 4/14/18 /,.1, �/) I WELL/PUMP PERMIT <br />