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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1668 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232 (209)468-3420 <br /> NON-REFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES 'I YEAR FROM DATE ISSUED <br /> JOBADDRESSO S Pershing Ave & Church St crrr/zIP Stockton, CA 95206/95203 Rl <br /> rr <' J v <br /> CRosssTREEr Navy Rd and Garfield Ave qpN b)Ec, I�^��� PARCEL SIZE LAND USE APPLICATION# A <br /> m <br /> OWNER NAME City of Stockton - Public Works Department PHONE (209) 937-8411 <br /> OWNER ADDRESS 22 E. Weber Avenue, Room 301 CITY/STATE/ZIP Stockton, CA 95202 <br /> CONTRACTOR V&W Drilling, Inc. PHONE 209-469-7700 <br /> CONTRACTOR ADDRESS 1133 BLACKHURST DR CITY/STATE/zip Galt, CA 95632 <br /> SUBCONTRACTORICONSULTANT Wallace-Kuhl &Associates PHONE 916-997-1546 <br /> SUBCONTRACTOR/CONSULTANTADDRESS 3050 Industrial Blvd CITY/STATE/ZIP West Sacramento, CA 95691 <br /> LICENSE VC-57 ❑`C61 11D-09 [I Other NUMBER # 720904 EXPIRATION DATE 4/30/2022 <br /> BILLING PARTY: hrOWNER ❑CONTRACTOR ❑ SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria(4391)❑ Dibromochloropropane(4392)❑ Arsenic(4393) <br /> INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring Soil Sampling/Characterization <br /> ❑ Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ❑ New Well ❑ Replacement Well 11 Well Alteration/Modification [I Other D1, D2, D3, D4, D5, D8 <br /> 11i9'Monitoring Well(s) #of wells Soil Boring(s) 6 #of borings ❑ Geotechnical #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal a Cross-Connection Repair <br /> C New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ❑ Mud Rotary ❑ Air Rotary VAuger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth 25 to 35 ft Excavation 6° in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br /> ❑ Conductor Casing In diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Schad ❑ Steel [iPlastic ❑ Stainless Steel 11Other <br /> Grout Seal Depth ;3S`�'�`- ft VT/Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement sack mix17 gal water <br /> Bentonite(20%solids) ❑ Other <br /> Grout Placement Method ❑ Pumped ❑ Free Fall V40ther Free fall via Tremie Pipe ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal❑Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP ❑ Submersible❑ Turbine ❑ Other HP Pump Set ft Standing Water Level 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 WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MI IMUM 48 HOUR ApVfilNCE NOTIC,L"REQUIRED FOR INSPECTIONS -PLEASE TCALL (209) 953-769 <br /> SIGNEDA4n // TITLE J ' /'C ' / a'r C Z7 DATE � C L <br /> f <br /> a <br /> 7 V� <br /> ..Rf <br /> DEPARTM ENT USE ONLY /t <br /> Application Accepted By Date 7/--//,? I Area S�JEmployee ID# <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By- Date l Constructed Well Depth ft <br /> COMMENTS jj _- <br /> PE sc Received Amount Date Permit/ Invoice# Well ID# <br /> Codes Info Bv Cash Remitted Service Re uest# <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />