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��ljo L WELUPUMP PERMIT ��SOAQUIN COUNTY ENVIRON z. HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(20 468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE <br /> Ul <br /> JOB ADDRESS Between Port Rd L and Port Rd M CITY/ZIP Stockton/9520 <br /> D <br /> CROSS STREET Port Rd 21,22,and 23 APN 14503012 PARCELSIZE 167 aC LAND USE APPLICATION# o <br /> z <br /> OWNER NAME Port of Stockton PHONE (209)946-0246 y <br /> OWNER ADDRESS 2201 West Washington Street CITY/STATE/zip Stockton/CA/95206 <br /> CONTRACTOR PHONQ (9146)W 451" <br /> CONTRACTOR ADDRESS 286A Prnzpg"&k CITY/STATE/ZIP Rmycho <br /> SIMCONTRACTOR Taber Drilling PHONE (916)371-8234 <br /> ONTRACTOR ADDRESS 536 Galveston Street CITY/STATE/zip West Sacramento/CA/95691 <br /> LICENSE X C-57 ❑C-61 ❑D-09 ❑Other NUMBER RRA710N DATE 2-28-2018 <br /> DOMESTIC WELL SAMPLING:I I General Minerai/Coliform Bacteria(4391)1 1 Dibromochloropropane(4392)1 1 Arsenic(4393) <br /> INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring 30 Soil Sampling/Characterization <br /> 0 Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> ❑Monitoring Well(s) #of wells ❑Soil Bodng(s) #of borings X1 Geotechnical 13 #of bon ngs <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ❑New Pump ❑Pump Replacement ❑Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ❑ Mud Rotary ❑Air Rotary 9 Auger ❑Cable Tool ❑Push Point ❑ Other <br /> Proposed Well Depth 30 ft Excavation 5 in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diame in Thickness/Gauge/ASTM Sched D Steel 11 Plastic ❑Stainless Steel [I Other <br /> Grout Seal Depy, It R Neat Cement(94 1b bag/5-10 gal water) ❑Sand Cement sack mix/7 gal water <br /> ❑ Bentonite(20%solids) 0 Other <br /> Grout Placement Method ❑Pumped X Free Fall ❑Other 0 Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> ❑Concrete Pedestal❑Dimensions:Width ft Length ft Thick in ❑Christy Box D Stove Pipe <br /> PUMP ❑Submersible❑Turbine ❑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 /> MINIMUM 24 HOU ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED — TITLE Field Engineer DATE 12-27-2017 <br /> IF <br /> ticCO <br /> QUgy <br /> CAt 4j <br /> 00, <br /> PATMENT U E 0 LY 4/E <br /> Application Accepted By to � Area Employee ID# <br /> Grout Inspection By Date ❑ PECIAL Well Permit <br /> Pump Inspection By Date 0 if 01 ❑ WAIVER Received <br /> Soil Boring Inspection By ate Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ ountDate PermiU Invoice# Well ID# <br /> Codes Info Cash emitted Service Re uest# <br /> Z O <br /> EHD43-06 8/01/16 / "/CYL Oe�{-� WELL/PUMPPERMIT <br />