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l 40 <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 -6232 (209) 468-3420 <br />NUN -REFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 22331 E. Skiff Rd. _ CITY/ZIP Escalon/95320 <br />CROSS STREET Temple Creek Rd. APN 205-19-003 PARCEL SIZE 60.09 LAND USE APPLICATION # <br />OWNER NAME Wagner Dairy - Dustin Wagner _ PHOHE 209-652-5192 <br />OWNER ADDRESS 22176 E. Skiff Rd" _ CITY/STATE/ZIP Escalon/95320 <br />CONTRACTOR Delta Pump Co. PHONE 209-466-9625 <br />CONTRACTOR ADDRESS 646 S. California St. CITYISTATE21PSt♦ ockton/95203 <br />SUBCONTRACTOR/CONSULTANT PHONE <br />SUBCONTRACTOR/CONSULTANT ADDRESS CITYISTATE/ZIP <br />LICENSE 1 C-57 X C-61 D-09 Other NUMBER 1055434 EXPIRATION DATE 7,,31,12011 <br />BILLING PARTY: OWNER CONTRACTOR I I SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL. SAMPLING: -1 General Mineral/Coliform Bacteria (4391) J Dibromochloropropane (4392) -1 Arsenic (4393) <br />INTENDED USE 1 DomesticrPrivatc X Irrigation;Agricultural - Industrial _ Water Quality Monitoring C Soil Sampling./Characterization <br />U Public Water System <br />f di`f rcr' `Ic r Avrel. Water Syslsrn Narnc Contact Name or Phone Ntark - <br />TYPE OF WORK IJ New Well I Replacement Well Well AlteratioruModification Other <br />Il Monitoring Wells) # of wells - Soil Boring(s) * "t r°"rg` f Geotechnical <br />I Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />New Pump X Pump Replacement .1 Pump Repair Raise Well Casina <br />C <br />Sq 46V41DI tiling Method -i Mud Rotary L Air Rotary Ll Auger LI Cable Tool _ Push Point _ Other N J0A <br />Proposed Well Depth It Excavation in diameter I i Open Bottom ; I Gravel Pack €Aj ie N41E �' iTJ'4,eI r <br />J Conductor Casing In diameter / Conductor Casing Depth It RT41 t <br />Well Casing Diameter _ in Thick ness;Ga uge,ASTM Sched 1, Steel Plastic I Stainless Steel Other ENT <br />Grout Seal Depth ft _ Neat Cement (94 /b ba915- 10 gat water) _ Sand Cement sack ma gal ,Dater <br />I Bentonite (20% solids) I Other <br />Grout Placement Method . Pumped J Free Fall Other I Retardant? Accelerator enamel <br />PEDESTAL Installed By Driller Pump Contractor - Other <br />J Concrete Pedestal -(Dimensions Width ft Length It Thick in - Christy Box I Stove Pipe <br />PUMP J SubmersibleX Turbine _ Other HP _Z5_ Pump Set 16Q It Standing Water Level 100 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 I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />RI/�G Ai^Tlf`G C;G/l! IIOCf1 FOR ",I—NIS P"n ee rn r r (1n0l oc� 7&o- <br />1 f'IIVVV V m1 c rntitI\LV V• MV IVI�V - /IVV. V/\i�►iVVI V_t VV <br />SIGNED_ TILE CEO DATE 7/16/2021 <br />DEPARTMENT USE ONLY <br />Application Accepted By—/�- ` Date 7 `'% ✓ ! Area 'J C/ Employee ID# <br />Grout Inspection By Datep I SPECIAL Well Permit <br />Pump Inspection By _LLX X [ 2A I WAIVER Received <br />Soil boring Inspection By Date Constructed Well Depth ft <br />COMMENTS LCGrr I��G�g2ne sz <br />T <br />m <br />D <br />0 <br />0 <br />D <br />nl <br />� H <br />PE <br />SC ReceivedCheck#/ <br />Info <br />Amount <br />Remitted <br />Date <br />Permit) Invoice # Well ID# <br />Service Request # <br />�JCo(des <br />EHD 43 -DG 6111/1019 -NELL fPUIYr PERMIT <br />