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NON-REFUNDABLE PERMIT CA.L (209) 953-7697 FOR INsQ,ECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 1121 McCloy Ave (_(DO 1-4-Lovrktry ardzip Stockton/95203 <br />r <br />4, „ ,-,1( 62 acres <br />CROSS STREET Port of Stockton Expy ApN 10Z —LW3007 PARCEL SIZE LAND USE APPLICATION # <br />OWNER NAME Port of Stockton PHONE 209-946-0246 <br />OWNER ADDRESS 2201 West Washington Street <br />CITY/STATE/ZIP Stockton/CA/95203 <br />CONTRACTOR Conetec PHONE 510-357-3677 <br />CONTRACTOR ADDRESS 820 Aladdin Ave <br />CITY/STATE/ZIP San Leandro, CA 94577 <br />SUBCONTRACTOR Haley & Aldrich Inc <br />PHONE 925-949-1012 <br />SUBCONTRACTOR ADDRESS 2033 N Main St Unit 309 <br />CITY/STATE/ZIP Walnut Creek CA 94596 <br />LICENSE a C-57 0 C-61 0 D-09 E Other NUMBER 1049248 EXPIRATION DATE 01/31/2023 <br />DOMESTIC WELL SAMPLING: 0 General Mineral/Coliform Bacteria (4391) 0 Dibromochloropropane (4392) 0 Arsenic (4393) <br />Pump Set ft Standing Water Level ft HP Submersible E Turbine E Other PUMP <br />ft Thick <br />PEDESTAL Installed By 0 Driller U Pump Contractor 0 Other <br />Concrete Pedestal Li Dimensions: Width ft Length <br />in E Christy Box E Stove Pipe <br />E Water Quality Monitoring E Soil Sampling/Characterization INTENDED USE E Domestic/Private E Irrigation/Agricultural II Industrial <br />If different from Owner: Water System Name Contact Name or Phone Number <br />Public Water System <br />Out-Of-Service Well Renewal <br />WELL CONSTRUCTION <br />Drilling Method <br />Proposed Well <br />c K <br />Grout Seal <br />in diameter <br />E Plastic in <br />TYPE OF Wow U New Well 0 Replacement Well <br />Monitoring Well(s) # of wells <br />Out-Of-Service Well <br />New Pump U Pump Replacement E Pump Repair <br />11 Cable Tool 0 Push Point E Other Mud Rotary <br />Depth ft <br />Conductor Casing <br />E Air Rotary U Auger <br />Excavation <br />in diameter <br />i diameter 1 2022 <br />QuiN <br />/ Conductor Casing Depth ft <br />Diameter <br />Depth <br />Bentonite (20% solids) 0 Other <br />Grout Placement Method 0 Pumped U Free Fall 0 Other <br />AOrkater <br />LIEN 7, <br />Well Alteration/Modification IXOtherlq x CPT (Geotechnical) <br />SOB Boring(s) # of borings 0 Geotechnical # of borings <br />SAN <br />Thicknezs/9,auge/ASTM Sched 0 Steel 0 Stainless Steel <br />ft lsat Cement (94/b bag/5-10 gal water) USand Cement HEAL <br />/110'.Cf" rlfr <br /> E Retardant / Acce4erat6r (name) <br />PA YAI <br />RECE/141or <br />E Open Bottom 0 Gravel Pack/Gravel SizekAR f <br />El Cross-Connection Repair <br />0 Raise Well Casing <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 />1 Cy <br />Ey AR TM EN T up E ONLY <br />Date 3A I /2b2-e- Area <br />65-1S140WIM <br />Employee ID# Application Accepted By 4IP / / <br />Grout Inspection B Date 0 SPECIAL Well Permit <br />Pump Inspection By Date 0 WAIVER Received <br />Soil Boring Inspection By Date <br />COMMENTS (pi 4-ra (---tb Witty dC j g fe-ki <br /> <br />Jt <br />Constructed Well Depth <br />tlf <br /> <br />1 WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />PE <br />Codes <br />SC <br />Info <br />Received <br />,13,x.-1 <br />ClcV#P <br />sh <br />Amount <br />Remitted Date Permit/ <br />Service Request # Invoice # Well ID# <br />i4 3T2. i 50 zji- ._303/2— 32 (i 3////27-- ‘,Kr P 0045 o(a6 <br />cn <br />C <br />cn <br />EHD043-06 10/2512021 Page 1 of 2 Well / Pump Permit