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0 <br />I <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />MUIV-KEFUNDABLE PERMIT www .s gov.org/end _ LXPIKES 7 YEAR FROM DATE ISSUEC <br />JOB ADDRESS 300 Port Rd 21 — Rom 1 W!!5 rt j Dri cmgb, n Stockton, CA 95203 <br />CROSS STREET Port Rd K APN 145030012 PARCEL SIZE171.9 a¢.ANO USE APPLICATION # <br />OWNER NAME port of Stockton Debbie CaUi PHONE 209 946 0246 <br />OWNER ADDRESS 2201 West Washington St CITY/STATEIZ� Stockton, CA 95203 <br />CONTRACTOR Salem Engineering Group PHONE 559 207 9768 <br />CONTRACTOR ADDRESS 4729 W Tacquelyn CITY/$TATE/LP Fresno, CA 93722 <br />SUBCONTRACTORICONSULTANT Middle Earth GeoTesting Inc. PHONE 714 633 5025 <br />SUBCONTRACTOR/CONSULTANT ADDRESS 954 North Lemon St. CT'/STATEMP XKg@llD9WS'J Orange CA 92867 <br />90M899451 <br />LICENSE X C-57 C-61 D-09 �vOther NUMBER EXPIRATION DATE wam 6/30/21 <br />BILLING PARTY: OWNER XCONTRACTOR SUBCONTRACTORICONSULTANT <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE Domestic/Private irrigation/Agricultural Industrial Water Quality Monitoring X Soil Sampling/Characterization <br />Public Water System <br />N dAweM from O�r Water System Name Contact Name or Phone Number <br />TYPE OF WORK New Well Replacement Well Well Alteration/Modification X Other CPTs <br />MonitoringWell(s) #of wells SoilBoring(s) #ofbodngs XGeotechnical X 3 0orbonng5 <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair 50 feet <br />Drilling Method Mud Rotary Air Rotary Auger Cable Tod Push Point Other _CPTs <br />Proposed Well Depth_50 it Excavation Push 2 inch in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter I Conductor Casing Depth ft <br />Well Casing Diameter _ in Thidmess/�G�auge/ASTM Sched Steel Plastic Stainless Steel Other <br />Grout Seal Depth 50 feetfl XNeat Cement (94 /b bag/S-10 gal water) Sand Cement sack mixf7 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method Pumped Free Fall XOther Tremmie Retardant / Accelerator (name) <br />PEDESTAL NA Installed By Driller Pump Contractor Other <br />_ Concrete Pedestal Dimensions: Width H Length it Thick in Christy Box Stove Pipe <br />PUMP Submersible Turbine Other HP Pump Set ft Standing Water Level fl <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 ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />MINIMUM 48 HOE A�VANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED_i,�-- SC t, TITLE Prnj naict DATE May10, 2021 <br />_i■■■■■■■■■■■ <br />1■■■■■■■■iii©I)! <br />■■■■■■■■■■ <br />Application Accepted By!/� Date S �� % Ar; ` S Employee ID# <br />Grout Inspection By Dale SPECIAL Well Permit <br />Pump Inspection By D WAIVER Received <br />Soil Boring Inspection ByZ Constructed Well Depth ft <br />COMMENTS <br />F SMF <br />y <br />, O 2021 <br />Co <br />'pqR � �NTY <br />FNr <br />EHD 43-06 6171/2019 /Y WELL (PUMP PERMIT <br />