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WELUPUMP PERMIT <br /> SAN JoAdUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1863 EAST HAZELTON AvENUE-STOacroN CA 95205-6232(209)468-3420 <br /> NON-REFUNDABLE PERMIT www.sjgov.oEWehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> Joe Aei> .. Cromwell Ave,at Ellsberq Dr. Port of Stockton CrrYrLP Stockton 95203 so <br /> cRoss STREET See"Job Address"above — i <br /> APN 16203007 PARCEL SIZELARD usE APPUCATxm x N/A _ <br /> OWNER NAME Port of Stockton <br /> PHOS (209)946-0246 <br /> OWNER AaDRFss PO Box 2089 _ _ CITYISTATE2s Stockton,CA 95201 <br /> CONTRACTOR Geo-Ex Subsurface Exploation PHS (916)799-8198 <br /> CONTTtACTOR ADOREss_ 1510 Madera Drive CITYISTArEIZP Dixon,CA 95620 <br /> SUBCONTRACTORTCON.0 LTANT N/A PHS <br /> SUBCONTRACTOR/CONSULTANT AOCI ESS CITYISTATE/ZP <br /> LICENSE N C-57 -C-61 D-09 Other NumsER 954267 ExPIRATIONDATE 2{L <br /> BILLING PARTY: ;OWNER ;'CONTRACTOR :SUBCONTRACTDR/CONSULTANr <br /> DOMESTIC WELL SAMPLING: General Mineral/C011forrn Bacteria(4391)I:Dibromorhl r propane(4392)n Arsenic(4393) <br /> MTENDED Use Do—polPnvate L Imgatlon/AgriCultural Industrof -Water Quality Monitoring F.Soil Sampling/Charectenzahon <br /> Public Water System N/A <br /> I'di"mm�final o. wean sntnn Nrin c--Nw-n�'hona Nmlxv I <br /> TYPE OF WORK New Wcll :1 Rnplocenv:nt Well r,Well Allerabon/Modtralion X Other Cone Penetration Tests \ 1 <br /> Monitoring Wallis) H of wells ,i Soil Bonrg(s) "O—w -Gmtechnuai ..,I <br /> Out-Of Semce Well :,Out-OfSemce Well Renewal n CTOSS-Connecllon Repair <br /> New Pump Purrip Replacement fl Pump Repair Raise Well C-,rq <br /> WELL CONSTRUCnON <br /> Drilling Method Mud Rotary Air Rotary Auger -Cable Tool Push Point x Other Cone Penetration Telt(direct push) <br /> Proposed Well Depth 100 R Exravabon 2 in diameter Open Bottom i;Gravel Pack/Gravel S¢c NA in diameter <br /> Conductor Ca.mg NA in diameter / Conductor Casing Depth NA R <br /> Well Casing Diameter NA in Thickness/Gauge/ASTM Schad NASteel D Piastre Stainless Sleel i;Other <br /> Grout seal Depth 100 R x Neat Ccmem(04lb bag/5-/0 gal water) O Sand Cement Sark mog gal water <br /> Be"tome(20%Sold") ,Other <br /> Grout Placement Method r Pumped i Free Fall X Other Tremle tube Retardant/Accelerator(nano) <br /> PLULKTAl Installed By i-.Driller .,Pump Contractor Othrr <br /> i Concrete Pedestal i Dimensions:Width it Length R ThiCk .n Christy Box ;'Stove Pipe <br /> i13MIC Submorsible.;Turbine _Other HP Pump Set R Standing Water Level R <br /> 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 /> MINI VANCE NOTICE REQUIRED FOR IINN�SPPECT( NS--P.-LEASE CALL(209)953-7697 <br /> 77 <br /> SIGNED TITLE 1 (CS I 1 DATE J <br /> 71 RF YMFNT <br /> MAR 23 ?0?U <br /> - - - �RvP/NRCC <br /> 4THDEgTr�ry <br /> D N T U E N L)Y <br /> 1 .I y T <br /> Applirahon Accepted By V ' to L� Area t Employee ID,# <br /> Groin Inspection By: Data SPECIAL Well Perrnit <br /> Pump Inspection By _ Date WAIVER Received <br /> Sod Boring Inspection By v r',1 ,.510 , i L•H - Date S�(t u _ Constructed Well Depth R <br /> COMMENTS <br /> PESC RsceWed C1NN:I l Amount Dab PorTn81 Invoice/ Wall IDI <br /> Codes Info CtOh Ram R utet0 - <br /> 1 L it C _4 il <br /> cro race rrllxls wLLL vuwpLlw, <br />