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B <br />WELL/PUMP PERMIT P ✓ ra <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />IYUIY-KtFUNUAbLt YtKMI I <br />JOB ADDRESS <br />1950 Port Road A Street <br />CROSS STREET <br />Port Road 4 <br />OWNER NAME <br />Port of Stockton <br />OWNER ADDRESS <br />PO BOX 2089 <br />CONTRACTOR <br />California Push Technoi, <br />CONTRACTOR ADDRESS 820 Aladdin Avenue <br />.ALL (2Ut0) 1f03-f13U1 FUR INSPECTIONS tAF9Kt0 T YEAR FROM DATE ISSUED <br />CITY/ZIP� Stockton, 95205 <br />APN 145-020-049.99& PARCEL SIZE LAND USE APPLICATION # <br />fff PHONE 209-946-0246 <br />CITY/STATE/ZIP Stockton, CA 95201 <br />)ies,Inc. PHONE 510-357-3677 <br />CITY/STATE/ZIP San Leandro, CA 94577 <br />SUBCONTRACTOR ADDRESS <br />LICENSE X C-57 1-1 C-61 Lj D-09 I_, Other <br />PHONE <br />CITY/STATE/ZIP <br />NUMBER 884827 EXPIRATION DA <br />DOMESTIC WELL SAMPLING: i General Mineral/Coliform Bacteria (4391) IJ Dibromochloropropane (4392) ! i Arsenic (4393) <br />NTENDED 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 I � New Well I.: Replacement Well P Well Alteration/Modification L Other <br />Monitoring Well(s) # of wells X Soil Boring(s) 4 # of borings - Geotechnical 4 At of borings <br />Out -Of -Service Well i 1 Out -Of -Service Well Renewal 7 Cross -Connection Repair <br />i I New Pump P Pump Replacement P Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method Mud Rotary Air Rotary 7 Auger Cable Tool _ Push Point X Other Cone Penetration Test (CPT) <br />Proposed Well Depth 100 ft Excavation 2 in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br />I Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Schad I Steel P Plastic r' Stainless Steel 11 Other <br />Grout Seal Depth 100 ft X Neat Cement (94 lb bag/5-10 gal water) C Sand Cement sack mixf7 gal water <br />I Bentonite (20% solids) i Other <br />Grout Placement Method X Pumped r I Free Fall X Other TrPmmiP ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By I.: Driller I Pump Contractor I Other <br />Concrete Pedestal = Dimensions: Width It Length ft Thick in Christy Box J Stove Pipe <br />PUMP Submersible;_ Turbine Other HP X 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. 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 COMPENSATION LAWS. <br />8 H <br />MINIM(lVtQUR.DVAANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED ( I� orf- TITLE RMO DATE 08/27/2018 <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />TMENT�I � LY <br />.� Date ��JJ <br />Data <br />Date <br />Date <br />� 201 <br />uN'V <br />j0tt NZp,1, <br />DEPp,4t'TME0 <br />t ti <br />Area Employee ID#/ l <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth ft <br />PE Sc Received Check#/ Amount Permit/Codes Info B Cash emitted Da Service Re uest # Invoice # WeI11D# <br />ASO.3ACZ 1 GOP00 <br />EHU 43-06 revised 4/14/18 WELL /PUMP PERMIT <br />