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+ 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 Port Road 13 and Port Road 11 between Port Road H and Port Road G CITY/ZIP Stockton,CA.95201 m <br /> 14503001 r <br /> CROSS STREET West Washington Street APN PARCEL SIZE 5553 noes LAND USE APPLICATION# o <br /> OWNER NAME Port of Stockton PHONE 209-946-0246 <br /> OVMrR ADDRESS 2201 West Washington Street CITY/STATEIZIP Stockton/CA/95201 <br /> CONTRACTOR Salem Engineering Group,Inc. PHONE (559)271-9700 <br /> CONTRACTOR ADDRESS 4729 West Jacquelyn Avenue CITY/STATEIZIP Fresno,CA.93722 <br /> SUBCONTRACTOR Salem Engineering Group, Inc. PHONE (559)271-9700 <br /> SUBCONTRACTOR ADDRESS 4729 West Jacquelyn Avenue CITYfSTATEIZIP Fresno,CA.93722 <br /> LICENSE Q C-57 D C-61 ❑D-09 ❑Other NUMBER 970772 EXPIRATION DATE 3/31/2020 <br /> DOMESTIC WELL SAMPLING:L General Mineral/Coliform Bacteria(4391)L Dibromochloropropane(4392)L Arsenic(4393) <br /> INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural 0 Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System <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 Ig Soil Boring(s) 11 not borings N Geotechnical 6 Nof borings <br /> ❑Out-Of-Service Well 0 Out-Of-Service Well Renewal O Cross-Connection Repair <br /> ❑New Pump 0 Pump Replacement 0 Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method 0 Mud Rotary 0 Air Rotary R Auger ❑Cable Tool 0 Push Point ❑ Other <br /> Proposed Well Depth 50 ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched 0 Steel ❑Plastic 0 Stainless Steel ❑Other <br /> Grout Seal Depth 50 ft Q Neat Cement(94/b bag/5-10 gal water) ❑Sand Cement sack mixf7 gal water <br /> ❑Bentonite(20%solids) ❑Other <br /> Grout Placement Method 0 Pumped D Free Fall &Other Trpmmia ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By 0 Driller ❑Pump Contractor ❑ Other <br /> ❑Concrete Pedestal❑Dimensions:Wdth ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP 0 Submersible❑Turbine 0 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 VE WITH,HE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS CO EN ATIONS. `y <br /> MI MiJ Fi A� NC NO D FO SPE�CTjIO�NS-PLEASE CALL(209)9 69 <br /> SIGNED TITLET.`iL�.b1lZJ��. DATE <br /> 'A 3 <br /> �0 <br /> RCOU <br /> �FpgR��HAY <br /> NT <br /> E ARTMENT /SE/ONLY LL <br /> Application Accepted ByA 11A ate' Area Employee ID#�� <br /> Grout Inspection By Date 11SPECIAL 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 hec Amount Permit/ <br /> Codes Info B s Remitted Date erviceRe uest# Invoice# WellID# <br /> EHD43-06 revised4n4/18 WELL/PUMP PERMIT <br />