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r 1 11 <br /> 1677 WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232 (209)468-3420 <br /> NON-REFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 19890 Skiff Rd. CITY/ZF_Escalon/95215 _ <br /> D <br /> CROSS STREET Maraposa APN 205-15-035 PARCEL SIZE 1.17 LAND USE APPLICATION# o <br /> A <br /> OWNER NAME Kathv Warren PHONE 209-629-1028 N <br /> OWNER ADDRESS SAME CITY/STATE/ZIP <br /> CONTRACTOR -Delta Pump CO. PHONE 209-466-%25 <br /> CONTRACTOR ADDRESS 646 S. California St. CITYISTATE21P Stockton/95203 <br /> SUBCONTRACTORICONSULTANT_ PHONE <br /> SUBCONTRACTORICONSULTANT ADDRESS CITYISTATE/ZIP <br /> LICENSE i C-57 X C-61 D-09 Other NUMBER 1055434 ExPIRATION DATE 713112021 <br /> BILLING PARTY: OWNER CONTRACTOR 1: SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING: -1 General Mineral/Coliform Bacteria(4391) , Dibromochloropropane(4392) -1 Arsenic(4393) <br /> INTENDED USE jd Domesticr'Private -1 Irrigatiorn-Agricultural - Industrial - Water Quality Monitoring r Soil SamplingiCharacterization <br /> Public Water System <br /> H diifereM from(Xvrel Water System Name Contact Name or Phone Numbe. <br /> TYPE OF WORK U New Well I Replacement Well Well AlterationiModification Other <br /> n Monitoring Well(s) #of wells - Soil Boring(s) a of bonrg`. F Geotechnical o/r,' <br /> 0 Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repan VC <br /> D New Pump X Pump Replacement I Pump Repair Raise Well Casing Sq <br /> WELL CONSTRUCTION NV Q(/ <br /> Df Ill Method Mud Rotary Au Rotary a Auger u Cable Tool _ Push Point _ Other ySA�THC MPA G <br /> Proposed Well Depth fl Excavation in diameter I i Open Bottom I I Gravel PackiGravel Size er <br /> J Conductor Casing in diameter ! Conductor Casing Depth It T <br /> Well Casing Diameter_ in Thick ness'Gauge:ASTM Sched I Steel Plastic 1 Stainless Steel Other <br /> Grout Seal Depth ft _ Neat Cement(94 Ib bag/510 gal water) _ Sand Cement sack mix!7 gal water <br /> 1 Bentonite(20%solids) P Other <br /> Grout Placement Method .. Pumped J Free Fall - Other t. Retardant!Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> I Concrete Pedestal-]Dimensions Width ft Length ft Thick in Christy Box 'I Stove Pipe <br /> PuMP X Submersible Turbine - Other HP 1.5 Pump Set ft Standing Water Level L.! 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 /> 1 "R ADVANCE NOTICE REQUIRED FOR INSPECTIONS PLEASE CALL (209) 953 <br /> SIGNED —'— � TITLE CEO — -- -- DATE 7/16/2021 <br /> Skiff Rd <br /> Skiff Rd Skiff <br /> - Skiff Rd Skiff Rd <br /> yr <br /> 1 <br /> SAI"f •117 <br /> • �(.M. fd <br /> -,� � 1 till'+Y:.lY..Y,r.ALI.:.:..�.w��:'qu-(GWrY•'� :.. <br /> w <br /> DEPARTMENT USE ONLY <br /> Application Accepted By � Z L' Date % / Area rEmployee ID# n� <br /> Grout Inspection By Date , I SPECIAL Well Permit <br /> Pump Inspection By , Date �Z 1 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth fl <br /> COMMENTS <br /> PE SC ReceivedCheck# Amount at Permit! Invoice# Well ID# <br /> Codes Info B s Remitted Service R uest# <br /> �3� l opo - <br /> EHD 43-06 61112015 <br /> Ye 3L rF'UM P PERMIT <br />