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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232 (209)468-3420 <br /> NON-REFUNDABLE PERMIT WWW.S OV.Or /ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> t ti <br /> JOB ADDRESS 9700 CITY21P Stockton 95203 <br /> CROSS STREET C V _APN 14503011 PARCEL SIZE 52.52 Acres LAND USE APPLICATION# N/A o <br /> m <br /> OWNER NAME NuStar Energy PHONE (209)943-5662 <br /> OWNER ADDRESS 2941 Navy Drive, Stockton,California CITY/STATE/ZIP Stockton,CA 95203 <br /> CONTRACTOR Taber Driling PHONE <br /> CONTRACTOR ADDRESS 536 Galveston,West Sacramento,CA CITY/STATE/ZIP <br /> SUBCONTRACTOR/CONSULTANT N/A PHONE (916)371 8234 <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/LIP -_ <br /> LICENSE X C-57 C-61 D-09 Other NUMBER 969927 EXPIRATION DATE 02.26.2022 <br /> BILLING PARTY: OWNER -i CONTRACTOR X SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED U Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring X Soil Sampling/Characterization <br /> Public Water System N/A <br /> If different from Owner. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well �j Replacement Well Well Alteration/Modification X Other One Cnnp.Penetration Test <br /> Monitoring Well(s) #of wells Soil Boring(s) p of borings Geotechnical a of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal � Cross-Connection Repair <br /> New Pump Pump Replacement Pump Repair Raise Well Casio <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point X OtherCone Penetration Test(direct push) <br /> Proposed Well Depth 80 It Excavation 2° in diameter Open Bottom Gravel Pack/Gravel Size_ NA in diameter <br /> Conductor Casing N/A in diameter / Conductor Casing Depth N/A ft <br /> Well Casing Diameter N/A in Thickness/Gauge/ASTM Sched N/A Steel - Plastic Stainless Steel Other <br /> Grout Seal Depth 80 ft X Neat Cement(94 Ib bag/5-10 gal water) Sand Cement sack mixl7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped Free Fall X Other Tremie Tube Retardant/Accelerator name <br /> Installed By Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width It Length ft Thick in Christy Box Stove Pipe <br /> PUMP Submersible Turbine Other HP Pump Set ft Standing Water Level h <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 /> M UM 48 UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE Executive Vice President DATE 07.31.2020 <br /> E% ENT <br /> LVED <br /> G 2020 <br /> TIV QUID/C <br /> OO <br /> IDpgEN7-AL Ty <br /> RMNT <br /> DEPARTMENT S ONLY <br /> Application Accepted By Date 7 �0d Area .S ^�» Employee ID# DA <br /> Grout Inspection By �a� Date �L� I SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring 1^<nA Ill n By _ Date Cru ted Well Depth ft <br /> COMMENTS_ S1Pt4- �'1rt/d./ 7jJf ih *t �-t <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Into Cash Remitted ServiceRequest# <br /> EH043-06 611112019 //..,. ^ 7 WELL/PUMP PERMIT <br />