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f <br />WELL/PUMP PERMIT i <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 INSS'PEC NS ( E 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS Port Road 13 and Port Road 11 between Port Road Hand Port Road G/Z(M(Ty Stockton/A2B4"- q -,2-0`j <br />IP <br />CROSS STREET West Washington Street APN 14503001 PARCEL SIZE 9593Aaes LAND USE APPLICATION # <br />OWNER NAME Port of Stockton PHONE 209-946-0246 <br />OWNER ADDRESS 2201 West Washington Street CITY/STATE0p Stockton/CA/95203 <br />CONTRACTOR Salem Engineering Group, Inc. PHONE (559) 271-9700 <br />CONTRACTOR ADDRESS 4729 West Jacquelyn Avenue CITY/STATE/ZIP Fresno/CA/93722 <br />SUBCONTRACTOR Salem Engineering Group, Inc. PHONE (559) 271-9700 <br />SUBCONTRACTOR ADDRESS 4729 West Jacquelyn Avenue CITY/STATE/ZIP Fresno/CA/93722 <br />LICENSE x C-57 ' C-61 i I D-09 I I Other NUMBER 970772 EXPIRATION DATE 3/3112090 <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) 1 1 Arsenic (4393) <br />INTENDED USE Domestic/Private i Irrigation/Agricultural , 1 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 WLII Replacement Well I I Well Alteration/Modification 1 Other <br />Monitoring Well(s) # of wells X Soil Boring(s) 9 # of borings X Geotechnical 9 a of borings <br />Out -Of -Service Well I Out -Of -Service Well Renewal Cross -Connection Repair <br />WELL CONSTRUCTION <br />Drilling Method Mud Rotary i Air Rotary x Auger Cable Tool Push Point 11 Other <br />Proposed Well Depth 20-50 It Excavation in diameter Open Bottom i i Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth It <br />Well Casing Diameter_ in Thickness/Gauge/ASTM Sched Steel Plastic I 1 Stainless Steel Other <br />Grout Seal Depth 20-50 It x Neat Cement (94 /b bag/5-10 gat water) Sand Cement sack mixf7 gal water <br />' Bentonite (20% solids) I I Other <br />Grout Placement Method 1 1 Pumped Free Fall M Other Tre 33p3je i i Retardant /Accelerator (name) <br />PEDESTAL Installed By I i Driller i Pump Contractor I ` Other <br />Concrete Pedestal I !Dimensions: Width ft Length ft Thick in i I Christy Box I i Stove Pipe <br />PUMP Submersible 1 ! Turbine I i Other HP Pump Set ft Standing Water Level It <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 TIVE WIT HE CALIFORNIA C RACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS C PE ATIONJS. <br />48 <br />SIGNED <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS 0111"m r f <br />82- �%At v"" <br />ED FOR INSPECTIONS -PLEASE CALL (209)953- <br />TITLE 4AO DATE <br />_0 <br />D <br />0 <br />mm <br />m <br />2418 <br />Tq1 <br />PA MENT U E O Y <br />Area EmployeelD#)Grp/ <br />Date I I SPECIAL Well Permit <br />Date 1 1 WAIVER Received <br />Date 40 tw ( Constructed Well Depth ft L <br />W, an A lth .t .o A,4 •rd1. <br />XA-Ali. elA <br />EHD 43-06 revised 4/14/10 <br />WELL /PUMP PERMIT <br />