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WELL/PUMP PERMIT P V/ <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT GALL ZU9 95J-7697 FOR INSPECTIONS hAPI1111=5 9 YEAR FROM DATE ISSUED <br />JOB ADDRESS 1200 Humphreys St <br />crrY21P Stockton 195203 <br />CROSS STREET W Fyffe St APN 16 OO7 <br />137242 <br />PARCEL SIZE LAND USE APPLICATION # <br />OWNER NAME Port of Stockton <br />PHONE <br />OWNER ADDRESS 2201 W. Washington St <br />CITY/STATE21P Stockton/ CA/ 95203 <br />CONTRACTOR Kleinfelder <br />PHONE 209-948-1345 <br />CONTRACTOR ADDRESS 2001 Arch Airport Rd Suite 100 <br />CITY/STATE/ZIP Stockton/ CA/ 95206 <br />SUBCONTRACTOR V & W Drilling <br />PHONE 209-469-7700 <br />SUBCONTRACTOR ADDRESS 3806 Duck Creek Dr <br />CITY/STATE/ZIP Stockton/ CA/ 95215 <br />LICENSE XC -57 ❑ C-61 -1 D-09 -1 Other <br />NUMBER 720904 EXPIRATION DATE 04/30/2018 <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) _. Dibromochloropropane (4392) Arsenic (4393) <br />NTENDED USE -1 Domestic/Private -1 Irrigation/Agricultural -' Industrial .7 Water Quality Monitoring fl 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 -1 Replacement Well -1 Well Alteration/Modification -1 Other <br />Monitoring Well(s) # of wells -1 Soil Boring(s) # of boring` )(Geotechnical # of borings <br />0 Out -Of -Service Well -1 Out -Of -Service Well Renewal 7 Cross -Connection Repair <br />Drilling Method ❑ Mud Rotary -1 Air Rotary X Auger ❑ Cable Tool 7 Push Point -1 Other <br />Proposed Well Depth 3-9 ft Excavation 4-6 in diameter -1 Open Bottom -1 Gravel Pack/Gravel Size in diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Schad E Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth ft XNeat Cement (94 lb bag15-10 gal water) -1 Sand Cement sack mW7 gal water <br />7 Bentonite (20% solids) -1 Other <br />Grout Placement Method ❑ Pumped Free Fall -1 Other -1 Retardant / Accelerator (name) <br />PEDESTAL Installed By i-1 Driller -1 Pump Contractor ❑ Other <br />:1 Concrete Pedestal Dimensions: Width ft Length ft Thick in Christy Box �] Stove Pipe <br />PUMP 7 Submersible❑ Turbine -1 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 />M-141MUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED _`_r_1� TITLE Staff Geologist I DATE 1/10/2018 <br />r -A <br />PA <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />= !- <br />T Data USE -Y <br />Date <br />Date <br />Date <br />Date <br />2418 <br />FA17" T <br />Area Employee ID#_j&* <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth ft <br />PermiV <br />Service Requost 0® r.. <br />EHD 43-06 8/01/16 (�,v* -#15-9t`17 WEI I HUMP PERMIT <br />