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I WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS o?.7,9 3 Pa;i R d D CITY/ZIP Stockton, CA 95203 <br />CROSS STREET Port Rd' 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 <br />CONTRACTOR ADDRESS <br />SUBCONTRACTOR <br />ConeTec, Inc <br />SUBCONTRACTOR ADDRESS <br />820 Aladdin Ave <br />CITY/STATE/ZIP <br />CITY/STATE/ZIP <br />PHONE (510)357-3677 <br />San Leandro, CA -94577 <br />PHONE <br />LICENSE x C-57 C-61 D-09 Other NUMBER 1049248 EXPIRATION DATE 01/31/2023 <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED 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 x Other 6 Cone Penetration Tests <br />Monitoring Well(s) # of wells Soil Boring(s) # of borings Geotechnical # of borings <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point x Other Cone Penetration Test (direct push) <br />Proposed Well Depth 100 ft Excavation 2-5 in in diameter Open Bottom Gravel Pack/Gravel Size N/A 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 100 ft x Neat Cement (94 Ib bagl5-10 gal water) Sand Cement sa�r <br />x Bentonite (20% solids) x Other Geotechnical CPT holes will be backfilled (sealed) with bentonite grout or 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 Christv Box Stove Pine <br />PUMP Submersible Turbine Other HP Pump Set ft Standing Water OeWl "'/r Vf <br />Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect to the following items. T <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 />NnAI,\II \1 '_1110t R Vu\,1A( I AOI I( I RI.OI IR1.1) fOR IA'�I'l.( I IOC, - I'll I. A"I_ ( \I.I-(_'or)) 9,3-7(,147 <br />DEPARTMENT USE ONLY <br />Application Accepted By jiL-- Date I /.q4? 0Z <br />Grout Inspection By z Date <br />Pump Inspection By Date <br />Soil Boring Inspection By Date <br />COMMENTS <br />Areaf 5f'.'Zk Employee ID# /rj <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth <br />ft <br />,r <br />m <br />D <br />v <br />v <br />m <br />m <br />N <br />PE <br />Codes <br />SC Received Check#/ <br />Info B ash <br />Amount Datp Permit/ Invoice # Well ID# <br />Remitted Service Re uest # <br />370 <br />IS7o <br />�a 2 <br />EHDa43-06 1025/2021 Page I of2 Well / Pump Permit <br />/3'72�Sr3CJ� 137576T73 <br />