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I (Poo <br />WELLIPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />IVVIV-KEFUNL)ABLE PERMIT <br />www.s19ov.0r9/ehd <br />EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 22176 Skiff Rd. <br />_. CITY/ZIP Escalon/95320 <br />CROSS STREET Temple Creek Rd. APN 205-20-002 PARCEL SIZE 158 <br />LAND USE APPLICATION # <br />OWNER NAME Wagner Dain -Dustin Wagner <br />- Pjc-b(f rd s fere, <br />1--L <br />PHONE 209-652_5192 <br />OWNER ADDRESS SAME_-- <br />CITY/STATE/ZIP <br />CONTRACTOR _DeltaPump Co. <br />PHONE 209-466-9625 <br />CONTRACTOR ADDRESS 646 S. California St. <br />CITY/STATE/ZIP Stockton/95203 <br />SUBCONTRACTOR/CONSULTANT _ <br />PHONE <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />CITY/STATE/ZIP <br />LICENSE i C-57 X C-61 D -CO Other <br />NUMBER 1055434 <br />EXPIRATION DATE 7/31/2021 <br />BILLING PARTY- OWNER CONTRACTOR I I SUBCONTRACTORICONSULTANT <br />DOMESTIC WELL SAMPLING: -1 General Mineral/Coliform Bacteria (4391) -1 Dibromochforopropane (4392) -1 Arsenic (4393) <br />INTENDED USE -1 Domestic;Pnvatc X IrrigatiowAgricultural - Industrial - Water OLIality Monitoring Soil SamplingrCharacterization <br />I Public Water System <br />If different from iatmer. Water System Name ontad Name or Phone Number /-�+ <br />_ Y, <br />TYPE OF WORK I New Well I Replacement Well Well AlterationiModification Other <br />-1 Monitoring Wells) # of :yells - Soil Borings) a qt honrg5 F Geotechnical <br />I Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />Nevi Pump X Pump Replacement I Pump Repair Raise Well Casinq <br />zJUN2 <br />EtiV)R QUIN C <br />Drilling Method -i Mud Rotary L Air Rotary � Auger U Cable Tool _ Push Point Other EgCTy 0NMQ� pp�r0 <br />Proposed Well Depth R Excavation in diameter I I Open Bottom i I Gravel Pack.Gravel Size_ _ in di9M�f <br />-J Conductor Casing in diameter i Conductor Casing Depth R <br />Well Casing Diameter _ in Thickness GaugerASTM Sched I I Steel Plastic I Stainless Steel Other <br />Grout Seal Depth ft _ Neat Cement (94 1b bag45- 10 gal water) _ Sand Cement sack rmxl7 gal water <br />I Bentonite (20% solids) I Other <br />Grout Placement Method _ Pumped J Free Fall _. Other Li Retardant? Accelerator (name) <br />PEDESTAL Installed By Driller PUMP Contractor Other <br />Concrete Pedestal rlDimensions Width R Length R Thick in - Christy Box n Stove Pipe <br />PUh9P X Submersible_ Turbine Other HP _JD Pump Set 147 it Standing Water Level 110 ft <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 1 AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />=164-ock- <br />8 i ' f,jVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNEDTfTLE CEO DATE _6/21/2021 <br />7� DEPARTMENT USE ONLY <br />Application Accepted By jam% Date G /� y Area tib Employee ID#_%�6 <br />Grout Inspection By Date I SPECIAL Well Permit <br />Pump Inspection By 4_ Date R �202� 1 WAIVER Received <br />Soil Boring Inspection By Date <br />COMMENTS <br />Constructed Well Depth <br />rn <br />PE <br />Codes <br />SC Received <br />Info B <br />eck Amount Permit/ <br />as Remitted 4ate rvice Re .est # Invoice # Well ID# <br />EH4 43-% 5n lr^r1+.9 rER •:n r <br />M <br />�T <br />D <br />Ty <br />r <br />