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2394 WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue - STOCKTON CA 95205-6232 - (209) 468-3420 NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED Joe ADDRESS 26851 CARTER RD. cryoP ESCALON CA 95320 CROSS STREET RSCAT-Ou RFT T 0TA APN �� ZSR-' Q� PARCEL SIZE 4 S - 78AND USE APPLICATION# OWNER NAME —RICHARD WAGNER r PHONE 652-5099 OWNER ADDRESS R A M F '12-2-1-76 k4« EpAy CITY/STATE/ZIP —c-6= (�= CONTRACTOR Delta P11MR GTOC'KTON ARMATURE & MOTOR WORKS 146Q. 209-466-9625 CONTRACTOR ADDRESS 646 S. California Street CITY/STATE/ZIP Stockton, CA 95203 SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE ❑ C-57 X C-61 O D-09 ❑ Other NUMBER 724778 ExPIRAT1oN DATE 08�1� GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section EIINTENDCDUSE 'qAomestic/Private O Irrigation/Agricultural O Industrial 0 Water Quality Monitoring 0 Soil Sampling/Characterization 0 Public Water System If different from Owner: Water System Narne Uontact Name or Phone Number TYPE OF WORK 0 New Well 0 Replacement Well O Well Alteration/Modification O Other O Monitoring Well(5) # of weffs C Sof(Boring() s # orborings 0 � Geotechnical--��+ O Out -Of -Service Well 0 Out -Of -Service Well Renewal ❑ Cross -Connection Repair " °�:C�II ❑ New Pum C Pum Replacement um Repair 0 Raise Well Casing , WELL CONSTRUCTION Drilling Method 0 Mud Rotary O Air Rotary 0 Auger ❑ Cable Tool 0 Push Point 0 Other 13 2018 Proposed Well Depthft Excavation in diameter 0 Open Bottom D Gravel Pack/Grav�0IV C ter 0 Conductor Casing in diameter / Conductor Casing Depth ft TNOEPAR MENT Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel Other Grout Seal Depth ft ❑ Neat Cement (94 lb bag/5-10 gal water) 0 Sand Cement sack mixl7 gal water ❑ Bentonite (20% solids) ❑Other Grout Placement Method ❑ Pumped 0 Free Fall ❑Other 0 Retardant /Accelerator (name) PEDESTAL Installed By ❑ Driller ❑Pump Contractor O Other ❑ Concrete Pedestal Dimensions: Width ft Length It Thick in 0 Christy Box ❑ Stove PIK) L.- --V RXubmersible0 Turbine O Other HP 3 Pump Set ft Standing Water Level ft I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPEN MINI M 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS SIGNED TITLE CEO DATE _ S 1 6/2018 PUMPWELL Is located approx. 40ft. from the back of the house passed the paved area. NOTE PUMP SET & STANDING WATER LEVEL IS UNKNOWN UNTIL THE JOB IS DONE t!,t j4C-HARD WAGNER DE 'ARTMENT USE O LY Application Accepted By Date Grout Inspection By Date Pump Inspection By Date �, I Soil Boring Inspection By COMMENTS Date Area Employee ID#X14� SPECIAL Well Permit WAIVER Received Constructed Well Depth ft WELL /PUMP PERMIT T m g X M