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1 WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT {� ,,fCALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />Joe ADDRESS _ 70;t P�i 11(/r CITY/ZIP Stockton, CA 95203 <br />CROSS STREET Port RCI X S APN 14502004 PARCEL SIZE 162.28 acres LAND USE APPLICATION # N/A <br />OWNER NAME Port of Stockton PHONE (209) 946-0246 <br />OWNER ADDRESS PO Box 2089 CITY/STATE/ZIP Stockton, CA 95201 <br />CONTRACTOR Taber Drilling PHONE (916) 371-8234 <br />CONTRACTOR ADDRESS 536 Galveston St CITY/STATE/ZIP West Sacramento, CA -95691 <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS CITYISTATE/ZfP <br />LICENSE X C-57 C-61 D-09 Other NUMBER 969927 EXPIRATION DATE 02/28/2022 <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />NTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring 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 Replacement Well Well Alteration/Modification Other. <br />Monitoring Well(s) # of wells Soil Boring(s) # of borings x Geotechnical 4 # of borings <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 x Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br />Proposed Well Depth 100 ft Excavation 2-5 in in diameter Open Bottom Gravel Pack/Gravel Size N/A i�lfi�rpeter <br />Conductor Casing N/A in diameter / Conductor Casing Depth N/A ft R IGG�� ��// <br />Well Casing Diameter N/A in Thickness/Gauge/ASTM Sched N/A Steel Plastic Stainless Steel Other <br />Grout Seal Depth 100 ft x Neat Cement (94 lb bag/5-10 gal water) Sand Cement sack mW7 gal <br />x Bentonite (20% solids) x Other Over water borings will be backfilled with bentonite and on shore borings with neat cement. <br />Grout Placement Method Pumped Free Fall x Other Tremie tube Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor Other <br />Concrete Pedestal Dimensions: Width ft Length ft Thick <br />in Christy Box Stove Pipe <br />PUMP Submersible Turbine Other HP Pump Set ft Standing Water Level ft <br />Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect to the following items: GPS <br />Coordinates, property lines, adjoining properties, water bodies or courses, drainage pattern, roads, existing wells, structures, <br />potential sources of contamination, sewers or private disposal systems. Include distance from two property lines. For Domestic, <br />Agriculture, Industrial well, provide location of any water wells or surface water within 200' radius of proposed well. <br />MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />DEPARTMENT USE ONLY <br />Application Accepted By/�- �` Date ' /�' %.✓ Area � S D( Employee ID# j <br />Grout Inspection By Date SPECIAL Well Permit <br />Pump Inspection By Date WAIVER Received <br />Soil Boring Inspection By 1 6(c, Date Z /1O/ Z?— Constructed Well Depth ft <br />COMMENTS <br />Fa <br />PE <br />Codes <br />SC Received <br />Info B <br />Check#/ Amount Permit/ <br />Cash Remitted Dae Service Reguest # Invoice # Well ID# <br />37�d <br />-5 - 22 �� <br />EHDO43-06 lOtB/2021 Page I of 2 Well / Pump Permit <br />A�,' 7# /37247S__ 1 <br />