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NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS <br />JOB ADDRESS awa o r Rol D <br />CROSS STREET Port Rd N ApN 14502004 <br />OWNER NAME Port of Stockton <br />OWNER ADDRESS PO Box 2089 <br />CITY/STATE/ZIP <br />EXPIRES 1 YEAR FROM DATE ISSUED <br />Stockton, CA 95203 <br />(209) 946-0246 <br />Stockton, CA 95201 <br />CrrylZip <br />PARCEL SIZE162 28 acres LAND USE APPLICATION # N/A <br />PHONE <br />CONTRACTOR Taber Drilling <br />PHONE <br /> (916) 371-8234 <br />CONTRACTOR ADDRESS 536 Galveston St <br />CITY/STATE/ZIP <br /> West Sacramento, CA-95691 <br />SUBCONTRACTOR <br /> <br />PHONE <br />SUBCONTRACTOR ADDRESS <br /> <br />CITY/STATE/ZIP <br /> <br />LICENSE X C-57 C-61 D-09 Other NUMBER 969927 EXPIRATION DATE 02/28/2022 <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 />I WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HokzELToN AVENUE - STOCKTON CA 95205 - (209)468-3420 <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />New Well Replacement Well <br />Monitoring Well(s) # of wells <br />Out-Of-Service Well <br />New Pump Pump Replacement <br />Soil Boring(s) # of borings <br />Out-Of-Service Well Renewal Cross-Connection Repair <br />Pump Repair Raise Well Casing <br />TYPE OF WORK Well Alteration/Modification Other <br />x Geotechnical <br /> ri of borings :SS3210(3V 311E WELL CONSTRUCTION <br />Drilling Method x Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br />Proposed Well Depth 100 ft Excavation 2-5 in in diameter Open Bottom Gravel Pack/Gravel Size N/A <br />PAr9ter 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 'el E•Al 7. <br />Grout Seal Depth 100 ft x Neat Cement (94/b bag/5-10 gal water) Sand Cement sack mix/7 gal ti a0 <br />x Bentonite (20% solids) x Other Over water borings will be backfilled with bentonite and on shore borings with 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 <br /> <br />ft Thick <br />in Christy Box Stovepipe <br />PUMP <br /> 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 />NIININI4 NI 24 1101. R NDVAN( \ (Y1 I(Ii: 12110 1121:1) I rR INSPIA I IONS - ( %.1I. 12119) 953-7697 <br />DEPARTMENT USE ONLY <br /> <br />Application Accepted By .."--- Z.,-/-,-. Date ///4/;.2 Area I/ S 64 IA ' 41 Employee ID# tii s <br />Grout Inspection By Date 3 I 4 I 2 -2— SPECIAL Well Permit <br /> <br />Pump Inspection By Date WAIVER Received <br /> <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />PE <br />Codes <br />SC <br />Info <br />Received Check#/ <br />, Cash <br />Amount <br />Remitted Da e Permit/ <br />Service Request # Invoice # Well ID# <br />43707 )6-0 <br />., eii4D <br />V iSet-- kCijd 1 fl 22- w-poOLA9.3 <br />L111)043-06 It /25/2021 Nse I of 2 <br />/372g.s-307 <br />Well /Pump Permit <br />NE'ElVilif?r) °IN Cr <br /> 7- r <br />2022 <br />chvr,o. <br />' rivr