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WELL/PUMP PERMIT /S '✓ <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468.3420 <br /> NON-REFUNDABLE PERMIT 9 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> • <br /> JOB ADDRESS 713 W.Luce Street /1200 Hum res CITY/ZIP�ort of Stockton,CA 95203 m <br /> /1372.42CROSS STREET Daly Drive APN162-030-07 PARCEL SIZE sLAND c <br /> USE APPLICATION# o <br /> z <br /> OWNER NAME Port of Stockton-Contact:Ms.Debbie Callie,Properties Manager PHONE 209.946.0246 N <br /> OWNER ADDRESS 2201 West Washington Stree P.O.BOX 2089 CITY/STATE/LR- Stockton,CA 95201 2 <br /> w <br /> CONTRACTOR V&W DrillingI ent PHONE Cell:209.981.7755 <br /> CONTRACTOR ADDRESS 1 133 Blackhurst Drive CITY/STATE/ZIP Galt,CA 95632 <br /> C <br /> SUBCONTRACTOR PHONE <br /> B <br /> SUBCONTRACTOR ADDRESS CITY/STATEIZJP <br /> LICENSE X C-57 C-61 D-09 Other NUMBER 720904 ExPIRATION DATE 04/30/2020 <br /> O <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) v <br /> 0 <br /> INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring - Soil Sampling/Characterization r. <br /> Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> n <br /> TYPE OF WORK New Well i Replacement Well Well Alteration/Modification i i Other Y <br /> Monitoring Wellg #of borings 10 <br /> Well(s) #of wells Soil Boring(s) X Geotechnical #of borings N <br /> Out-Of-Service Well Out-Of-Service Well Renewal i Cross-Connection Repair o <br /> New Pum Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION 1dl 7 se't <br /> Drilling Method X Mud Rotary Air Rotary X Auger Cable Tool Push Point Other <br /> Proposed Well Depth /JL/ 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 Sched Steel Plastic Stainless Steel Other <br /> Grout Seal Depth ful I depth ft X Neat Cement(94/b bag/5-10 gal wafer) Sand Cement sack mix/7 gal wa <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped Free Fall - Other Retardant/Accelerator(name) m Nr <br /> PEDESTAL Installed By I Driller IPump Contractor Other <br /> :I Concrete Pedestal iDimensions:Width It Length ft Thick in Christy Box i Stove I <br /> PUMP I Submersible I Turbine i Other HP Pump Set ft Standing Water Level 2018 <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LIC Q IN <br /> CURRENT ANDA TIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANC CO <br /> WORKERS C SATION LAWS. H D MEN- rY <br /> MI M 4 O �ANCEICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE Vice President,Engineering Services DATE 10/03/18 <br /> EPARTMENT USE ONLY <br /> Application Accepted By Date Area 3) 5� Employee ID# <br /> Grout Inspection By Date SPECIAL Well Perrillt / <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection ByDate Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Che Amount D to Permit/ Invoice# Well ID# <br /> Codes Info Remitted Service Re uest# <br /> 3 6 GAL <br /> EHU 43-06 revised 4/14/18 WELL/PUMP PERMIT <br />