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21019 <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205-6232 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 22176 E. Skiff Rd CITY21P Escalon 95320 m <br /> D <br /> CROSSSTREET Van Allan <br /> APN 2 0 5-2 0-0 0 2 PARCEL SIZE 15 8 LAND USE APPLICATION# 0 <br /> OWNER NAME Wagner Dairy PHONE 209-652-5192 v <br /> OWNER ADDRESS _Same CITY/STATE/ZIP <br /> CONTRACTOR Delta Pump gTnCYTO N ARMATURE & MOTOR WORKS IE00E. 209-466-9625 <br /> CONTRACTOR ADDRESS 646 S. California Street CITY/STATE/ZIP Stockton, CA 95203 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE . 0 C-57 XC-G1 ❑ D-09 ❑ Other NUMBER .724778 EXPIRATIONDATE 08/jA <br /> GEOGRAPHICAL INFORMATION: COOirdinates X YTownship Range Section <br /> INTENDED USE ❑ Domestic/Private f*Irrigation/Agricultural ❑ Industrial 0 Water Quality Monitoring 0 Soil Sampling/Characterization <br /> 0 Public Water System <br /> If different from Owner: Water Systern Name Contact Name or Phone Num er <br /> TYPE OF WORK 0 New Well ❑ Replacement Well 0 Well Alteration/Modification 0 Other <br /> 0 Monitoring Wells) #of wells 0 Soil Boring(s) #of borings ❑ Geotechnical #ofb <br /> 0 Out-Of-Service Well ❑ Out-Of-Service Well Renewal 0 Cross-Connection Repair O <br /> 0 New Pump ❑ Pump Replacement X Pump Repair 0 Raise Well Casing <br /> WELL CONSTRUCTION <br /> U Gy <br /> Drilling Method 0 Mud Rotary 0 Air Rotary 0 Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth ft Excavation in diameter 0 Open Bottom ❑ Gravel PackJGravei Size <br /> 0 Conductor Casing in diameter / Conductor Casing Depth It jP jr? <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched 0 Steel 0 Plastic 0 Stainless Steel D Other <br /> Grout Seal Depth ft ❑ Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement sack mix/7 gat water <br /> 0 Bentonite(20%solids) 0 Other <br /> Grout Placement Method ❑ Pumped 0 Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By 0 Driller ❑ Pump Contractor ❑ Other <br /> 0 Concrete Pedestal Dimensions:Width ft Length ft Thick in 0 Christy Box 0 Stove Pipe <br /> PUMP ,io Submersible0 Turbine 0 Other HP Pump Set ft Standing Water Level It <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 /> IRINi1DI <br /> .*Z41_Q,I,RAPVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED / TITLE CEO <br /> DATE 1 /31 12 01 9 <br /> PUMP/WELL is located next to the <br /> milking barn approx. 341.84 from m <br /> ! the Skiff Rd. r <br /> MILKING BARN <br /> -41 <br /> D <br /> P R T M E N T USE O N L Y <br /> Application Accepted By <br /> Date Area Employee ID# <br /> Grout Inspection By ( Date PECIAL Well Permit <br /> Pump Inspection By �n0b� _ Date _ WAIVER Received <br /> Soil Boring Inspection By Date�3 7- Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received a Amount Permit/ <br /> Codes Info B Cash Remitted Date Service Re uest# Invoice# <br /> Well ID# <br /> 7i 32�Z-� 2-8- WP <br /> EHD 43-06 <br /> 8/04/08 WELL/PUMP PERMIT <br />