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r � <br /> 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.sjgov.org/ehd EXPIRES')YEAR FROM DATE ISSUED <br /> JOB ADDRESS 300 Port Rd 21 �II� sh l►� Y•' CITY/ZIP Stockton,CA 95203 tDD� <br /> CROSS STREET Port Rd K API_145030012 PARCEL SIZE 171.9 2CLAND USE APPLICATION# A <br /> m <br /> OWNER NAME Port of Stockton Debbie Calli P HONE_209 946 0246 <br /> OWNER ADDRESS 2201 West Washington St ctrr/sTATEZP Stockton,CA 95203 <br /> CONTRACTOR Salem Engineering Group PHONE 559 207 9768 <br /> CONTRACTOR ADDRESS 4729 W Jacquelyn CITY/STATEIZIP Fresno,CA 93722 <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTORICONSULTANT ADDRESS CFTY/STATEZP <br /> LJCENSE X C-57 C-61 D-09 ��rrOthef NUMBER 970772 EXPIRATIONDATE 3-31-22 <br /> BILLING PARTY: OWNER XCONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> FL-ENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring X Soil Sampling/Characterization <br /> Public Water System <br /> If different from Outer Water System Name Contact Name or Phono Number <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells Soil Bodng(s) a of b""ils XGaotechnical 6 a of benngs <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair 15 to 50 feet <br /> New Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary XAuger Cable Tool Push Point Other <br /> Proposed Well Depth IS-50 ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter I Conductor Casing Depth h <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br /> Grout Seal Depth 15-50 feet ft X Neat Cement(94 Ib bag/5-10 gal wafer) Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped Free Fall XOther Tremmie Retardant/Accelerator(name) <br /> PEDESTAL NA Installed By Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width fl Length ft Thick in Christy Box 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 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED . J(i+�W �t.l TITLE Project Geologist DATE May 10,2021_ <br /> s FCE�NT <br /> qY FO <br /> , e IAL <br /> 1 p 2021 <br /> ­,,/DROMN Co <br /> F 'd <br /> pgR <br /> y <br /> DEPARTMENT USE ONLY /tel <br /> Application Accepted By LL Date S '�/ Area I tDe jj FqUi'Employee ID# <br /> Grout Inspection By-A Date SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount at Permit/ Invoice# Well ID# <br /> Codes Info ash Remitted Service R nest# <br /> 37a o 5a— I <br /> EHD 93-06 N11/2019 /J ' WELL/PUMP PERMIT <br />