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WELL/PUMP PERMIT <br />�N JOACIUIN COUNTY ENVIRONMENTAL HZ DEPT 1868 East Hazelton Avenue • STOCK T ON CP. 95205.8232 - (209) 468.3420 <br />)N -REFUNDABLE PERMIT 4rAI.L (20193) 953°7697 r-OI.INSPNCTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />3ADORESS 22176 SKIFF RD. CITYlZIP ESCALON 95320 <br />OSS STREET VAN ALLEN %APN 2 Q 5,*.` -2 0 — 0 0 t2 PARCEL SIZE 1 5 8 LAND.USE APPLICATION # <br />VNERNAME WAGNER DAIRY G(h A- :i-JV&tu LC4n>v�oNs 209 652-5009 <br />vNER ADDRESS �.SAMP- CITY/STATE/ZIP <br />NTRACTOR l)_,Jt a ,PUM1J . 8 j'jyC'KT(�N ARMATURE & MOTOR WORKS fft�oQ. 209-466-96 <br />+NTRACTORADDRESS 646 S6 California Street CITYISTATE/ZIP Stockton, CA 95203 <br />SCONTRACTOR PHONE <br />BCONTRACTOR ADDRESS CITY/STATE/ZIP <br />:t NSE EDC -57 X C-61 ❑ 0-09 0 Other NUMBER 724778 EXPIRATION DATE. 08/t� <br />;OGRAPHICAL INFORMATION: Coordinates X Y Township Range Section_ <br />rENDED USE ❑ Domestic/Private Akrigation/Agricultural 0 Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterizatlon <br />0 Public Water System <br />If different from Owner: Water y em Narris ontac', N arae or Phone Nurriter <br />PE OF WORK 0 New Well ❑ Replacement Well 0 Well Alteration/Modification 0 Other <br />0 Monitoring Well(s) # of wells 0 Soil Boring(s) 6 or borings 0 Geotechnice! <br />0 Out -Of -Service Well 0 Out -Of -Service Well Renewal 0 Cross -Connection Repair I� <br />0 New Pump 0 Pump Replacement31 P <br />gump Repel, 0 Raise Well Casing <br />:LL CONSTRUCTION ''' ; )0018 <br />illing Method 0 Mud Rotary ❑ Air Rotary 0 Auger ❑ Cable Tool 0 Push Point ❑ Other JOA1, UO <br />1(VU <br />oposed Well Depth ft Excavation in diameter 0 Open Bottom 0 Gravel Pack/Gravel`%AP 0 �-* ter <br />0 Conductor Casing in diameter / Conductor Casing Depth ft flr T�'F/yz <br />Well Casing Diameter In Thlcknese/Gauge/ASTM Sched 0 Steel 0 Plastic 0 Stainless Steel 0 Other <br />Grout Seal Depth ft 0 Neat Cement 1'94 !b bagl5-10 gal weter) ❑ Sand Cement sack m!x/7 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />-out Placement Method ❑ Pumped ❑ Free Fall 0 Other 0 Retardant / Accelerator (name) <br />:DESTAL Installed By 0 Driller 0 Pump Contractor 0 Other <br />❑ Concrete Pedestal Dimensions: Width ft Length ft Thick In ❑ Christy Box ❑ Stove Pipe <br />11-P 43,,Submersible❑ Turbine D Other HP 1_QPump Set it Standing,.Water Level 1 0 ft <br />HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />)AQUIN COUNTY ORDINANCES, 'STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />.lRRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />ORKERB COMPENSATION LAWS <br />— <br />A <br />i� <br />L, <br />EP.ARTMENT USE ONLY n <br />Application Accepted By V�l-A X 1vv-� Date 5 Area C Employee ID# <br />Grout Inspection By Date SPECIAL Well Permit <br />Pump Inspection By Datay Z 1Ty WAIVER Received <br />Soil Boring fnspection By Date Constructed Well Depth ft <br />COMMENTS <br />PE <br />Codes <br />SC <br />Info <br />Received <br />B <br />Chec <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Re uest # <br />Invoice # <br />Welt ID# <br />77 <br />v V <br />8/04108 WELL /PUMP PERMIT <br />