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e� <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />rrvvrv-rctrUNL)At%Lt rtHMI I / t ALL (L,U/Ui UO3-rby! f -UH INSPECTIONS r-AYIKtJ l YEAR FROM DATE ISSUED <br />JOS ADDRESS rvv- - slot /� b 1TU�p�'Q� 1 S CITymp Port of Stockton. CA 95203 <br />�— �—�1t�€AP'� <br />CROSS STREET Daly Drive APN ZU� <br />-���PARCEL SIZ 0,000 sf LA�1D P¢L,cTION# <br />OWNER NAME Port of Stockton - Contact: Ms. Debbie Calli, Properties Manager PHONE 209.946.0246 <br />OWNER ADDRESS 2201 West Washington Street CITY/STATE/ZIP Stockton, CA 95203 <br />CONTRACTOR West Coast Exploration PHONE 209.985.2663 <br />CONTRACTOR ADDRESS P.O. Box 133 CITY/STATE2iP Escalon, CA 95320 <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br />LICENSE X C-57 C-61 D-09 Other NUMBER 870761 EXPIRATIONDATE 01/31/2018 <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br />NTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System <br />If different from Owner: L;.niat Name or Phone NUrnber <br />TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br />Monitoring Well(s) # of wells Soil Boring(s) If of borings X Geotechnical 3 <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />* or borings <br />Drilling Method Mud Rotary Air Rotary X Auger Cable Tool Push Point Other <br />Proposed Well Depth 10-20 ft Excavation 4 1/2 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 Plastic Stainless Steel Other <br />Grout Seal Depth full depth ft X Neat Cement (94 111 bagl5-10 gal water) Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method X Pumped Free Fall Other 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 it 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. 1 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 CO E SATICN LAW'.% <br />MI M O�t1R ANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED 1 TITLEVice President, Engineering ServicesDATE 01/12/2018 <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />RqA TMENT SE ONLY �/��(�y�t//� <br />Date Area Employee ID#_kLL r <br />Date SPECIAL Well Permit <br />Date WAIVER Received <br />.pate Constructed Well Depth j � L � ft <br />PE SC Received <br />Codes Info By <br />Check#/ Amount <br />Cash Remitted <br />Date Permit/Invoice # Well ID# <br />Service Re uest # <br />4nu 2 <br />4/30/12 WELL /PUMP PERMIT <br />