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t <br />I WELUPUMP 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 CXPIKES 1 YEAR FROM LATE ISSUED <br />JOB ADDRESS ;1172 a I Port Rd D CITY/ZIP Stockton, CA 95203 <br />CROSS STREET Port Rd A APN 14502004 PARCEL SIZE 162.28 acres LAND USE APPLICATION # N/A <br />OWNER NAME Port of Stockton — o c k do R"{ } NO r ( e. PHONE (209) 946-0246 <br />OWNER ADDRESS PO Box 2089 CITY/STATE/ZIP Stockton, CA 95201 <br />CONTRACTOR ConeTec, Inc PHONE (510) 357-3677 <br />CONTRACTOR ADDRESS 820 Aladdin Ave CITY/STATE/ZIP San Leandro, CA -94577 <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE X C-57 C-61 D-09 Other <br />PHONE <br />CITY/STATE/ZIP <br />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 V Soil Sampling/Characterization <br />Public Water System NSA pal X< _ <br />If different from Owner: Water System Name Contact Name or Phone Number A <br />TYPE OF WORK New Well Replacement Well Well Alteration/Modification x Other O hone t'eneirailon I esis - "C / <br />s # of b04P <br />Monitoring Well(s) # of wells Soil Boring # of borings Geotechnical F�� R O <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair fT 6 ?) <br />New Pump Pump Replacement Pump Repair Raise Well Casing SAN <br />WELL CONSTRUCTION HEE tENV/RO IN C <br />Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point x Other Cone Penetration Test'�bii�cmp <br />Proposed Well Depth 100 ft Excavation 2-5 in in diameter Open Bottom Gravel Pack/Gravel Size N/A in diamete ' <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 lb bag/5-10 gal water) Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) x Other Geotechnical CPT holes will be backfilled (sealed) with neat cement grout. <br />Grout Placement Method Pumoed 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 />n 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 />\11AI111 N1 24 IIOt R kD\ VN(L NOII( I: RvQt IRI -1) FoR INSPIA I IU\S - I'LLASL (kLL (209) 953.7697 <br />DEPARTMENT USE ONLY <br />Application Accepted By <br />t L Date 6/02 <br />Grout Inspection By Date <br />Pump Inspection By Date <br />Soil Boring Inspection By <br />COMMENTS <br />Date <br />Area 15b kf �'1 Employee ID# <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth ft <br />'NT <br />ED <br />JIV Ty <br />PE Sc Received <br />Codes Info B <br />Check#/ Amount <br />Cash Remitted <br />Date Permit/ Invoice # Well ID# <br />ervice Re est # <br />qa 50 <br />0 <br />2L P 0 <br />EHDb43-06 10/25.2021Page I of 2 Well /Pumii� <br />p Pern <br />�/'��' Y ' <br />)q_1433/% <br />