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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.sjqov.org1ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> Jos ADDRESS 1121 McCloy Avenue <br /> I CITYZP Stocklon195203 �y <br /> CROSS STREET Port of Stockton Expy APN u(0 S OD / PARCEL SIZE 62a..,LAND USE APPLICATION x <br /> 6 0 <br /> A <br /> N <br /> OWNER NAME Port of Stockton PHONE(209)946-0246 N <br /> OWNER ADDRESS 2201 West Washington Street CITY/STATEZP Stockton/CA/95203 <br /> CONTRACTOR Gulf Shore Construction Services,Inc. PHONE (916)939-4117 <br /> CONTRACTOR ADDRESS 3362 Fags ld Rd.R.nUw C«dove,CA95742 CITY/STATEIZIP <br /> SUBCONTRACTOR/CONSULTANT Haley&Aldrich.Inc. PHONE(925)949-1012 <br /> SUBCONTRACTOR/CONSULTANT ADDRESS 2033N Main Sl UNIT 309 CITY/STATEZP Walnut Creek/CA/94596 <br /> LICENSE X C-57 U C-61 'i D-09 ❑Other NUMBER 964224 EXPIRATION DATE 8131/21 <br /> BILLING PARTY: fl OWNER ❑CONTRACTOR X SUBCONTRACTOR/CONSULTANT <br /> Do61ESTIC WELL SAMPLING:L General Mineral/Coliform Bacteria(4391)a Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE U Domestic/Privale D Irrigation/Agricultural ❑Industrial _,Water Quality Monitoring x Soil Sampling/Characterization <br /> Public Water System <br /> II dlle—t ears Oaner: Water System Name C-I d Nurse or Phone Number <br /> TYPE OF WORK C)New Well n Replacement Well rl Well Alleration/Modification X Other Geotechnical investigation <br /> I;Monitoring Well(s) A Of wells C Soil Borings) a of bodngs R Geotechnical-5& 48 lo-rings <br /> Out-Of-Service Well U Out-Of-Service Well Renewal --Cross-Connection Repair <br /> ❑New Pum C Pump Replacement 0 Pump Repair -,j Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method .:,Mud Rolary U Air Rotary ,L Auger C7 Cable Tool '7 Push Point A Other <br /> Proposed Well Depth Int 10i_R Excavation In diameter Open Bottom ❑Gravel Pack/Gravel Size In diameter <br /> Conductor Casing In diameter / Conductor Casing Depth R <br /> Well Casing Diameter_ In Thickness/Gauge/ASTM Schad 7,Steel L Plastic ❑Stainless Steel U Other <br /> Grout Seal Depth _R fd.Neat Cement(94 Ib bagl5-10 gal water) `i Sand Cement sack mixF7 gal water <br /> ..Bentonite(20%solids) L-1 Other <br /> Grout Placement Method P1 Pumped ❑Free Fag Li Other U Retardant/Accelerator(name) <br /> PEDESTAL Installed By u Driller ❑Pump Contractor 7 Other <br /> E Concrete Pedestal LOlmenslons:Width R Length ft Thick In C Christy Box L'Stove Pipe <br /> PUMP ^SubmersibleD Turbine r7 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 AC VE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS P N ATION L . <br /> INIM 4 A ANC TICE REQUIRED FOR <br /> R INSPECTION$Q-PLEASE CALL(209)953-.7/697 <br /> SIG D TITLE �EgIa��T /' ``-`� DATEIt I If I <br /> r A <br /> RE yMFN <br /> CFS� T <br /> Uf, 06 202 <br /> 0 <br /> FO <br /> T A Q / O <br /> I <br /> - AN <br /> opNT f <br /> FNT <br /> fl DEPARTMENT USE ONLY <br /> Application Accepted By E " Dale 6 17D Area 3 S faiFlJ1 r Employee IDs 1 <br /> Grout Inspection By Dale ❑ SPECIAL Well Permit <br /> Pump Inspection By 11 Date ❑ WAIVER Received <br /> Soil Boring Inspection By 'py,,s iS(I Dale 4 Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received Chaek/ll Amount Date Permit] Invoice p Well IDq <br /> Codes Info Cash Remitted Service rmRequest p <br /> z7� is [ �iG� J r I: <br /> EN04106 6/11/1019 lZI1,3dz "ELL rPUA!P PER/JR <br /> �� I � � ll2/q.3a8 � <br />