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,t FV eG <br />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 />JOB ADDRESS W. Washington St C TY21P Stockton 195203 <br />CROSS STREET McCloy Ave APN_ 14503017 PARCEL SIZE 6.16 LAND USE APPLICATION # <br />OWNER NAME Port of Stockton PHONE <br />OWNER ADDRESS 2201 W. Washington St CITYISTATE/ZIP Stockton/ CA/ 95203 <br />CONTRACTOR Kleinfelder PHONE 209-948-1345 <br />CONTRACTOR ADDRESS 2001 Arch Airport Rd Suite 100 CITY/STATE/ZIP Stockton/ CA/ 95206 <br />SUBCONTRACTOR V & W Drilling PHONE 209-469-7700 <br />SUBCONTRACTOR ADDRESS 3806 Duck Creek Dr CITY/STATE/ZIP Stockton/ CA/ 95215 <br />LICENSE XC -57 ❑ C-61 0 D-09 ❑ Other NUMBER 720904 EXPIRATION DATE 04/30/2018 <br />DOMESTIC WELL SAMPLING: -General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) -Arsenic (4393) <br />INTENDED USE -1 Domestic/Private -1 Irrigation/Agricultural -1 Industrial -1 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 -1 New Well -1 Replacement Well n Well Alteration/Modification -1 Other <br />-1 Monitoring Well(s) # of wells ❑ Soil Boring(s) # of boringsGeotechnical f # of borings <br />-1 Out -Of -Service Well ❑ Out -Of -Service Well Renewal 7 Cross -Connection Repair <br />vveu <br />Drilling Method 1 Mud Rotary 7 Air Rotary X Auger 7 Cable Tool -1 Push Point -1 Other <br />Proposed Well Depth 5-7 ft Excavation 4-6 in diameter -1 Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br />7 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 ft XNeat Cement (94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) -1 Other <br />Grout Placement Method -1 Pumped 'AFree Fall 7 Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller -1 Pump Contractor �-1 Other <br />Concrete Pedestal ]Dimensions: Width ft Length ft Thick in :1 Christy Box ❑ Stove Pipe <br />PUMP ❑ 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 />4M{j,NI U,M/24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED l= TITLE Staff Geologist I DATE 1/10/2018 <br />R qrM� <br />FCI��� r <br />qN �� O <br />�D <br />q{? , 18 <br />�E 'yFNoUN)Y <br />r <br />Area 3�s Employee ID# 6 <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth ft <br />Service Reques14' <br />lif■�r��rrtr � <br />EHD43-06 6/01/16 Ciw-'fr 0�� / 17 WELL /PUMP PERMIT <br />E P I R T M E N T S O L Y <br />Application Accepted By <br />ZE( <br />Date <br />Grout Inspection By <br />Date <br />Pump Inspection By <br />Date <br />Soil Boring Inspection By 1l <br />Date ; LO <br />COMMENTS <br />Area 3�s Employee ID# 6 <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth ft <br />Service Reques14' <br />lif■�r��rrtr � <br />EHD43-06 6/01/16 Ciw-'fr 0�� / 17 WELL /PUMP PERMIT <br />