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1F748 <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />IVVIV-i[EFUNUABLE PERMIT www.sjgov.org/end EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 22331 E. Skiff Rd. CITYrZIP E_scalon/9532_0 <br />'.CROSS STREETTemple Creek Rd. APN 205-19-003 -PARCEL SIZE6V.09LANDUSE APPLICATION # <br />OWNER NAME Wagner Dairy - Dustin Wagner-R)ckurc) 3 DteviA PHONE 2.09-401-222.7 _ <br />OWNER ADDRESS Skiff Rd. _ <br />_221-76-E.__ cITYlSTA7E/zIP Escalon/95320 <br />CONTRACTOR Delta Pump Co. PHONE 209-466-9625 <br />CONTRACTOR ADDRESS 646 S. California St. Cm/STATE/ZIP Stockton/CA/95203 <br />SUBCONTRACTOR/CONSULTANT <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />CITYISTATE(LIP <br />PHONE <br />CENSE i C -1W XC -61 D-09 Other NUMBER 1055434 EXPIRATION DATE 7/3 1/2023 <br />ILUNG PARTY: OWNER CONTRACTOR I i SUBCONTRACTORICONSULTAN7 <br />DOMESTIC WELL SAMPLING: -1 General Mineral/Coliform Bacteria (4391) -� Dibromochloropropane (4392) -1 Arsenic (4393) <br />INTENDED USE X DomesticrPrivale -1 Irrigation.'Agricultural - Industrial - Water Quality Monitoring F Soil SamplingrCharacterization <br />I Public Water System <br />If ddrerent 4cn !carer Water Syston Naim Contacl Name or Phone NuinL•e <br />TYPE OF WORK U New Well : Replacement Well Well AlteratiordModification Other <br />Monitoring Wells) # of wells - Soil Borings) 4 nt honngs t- Geotechnical � of a -, r1.7, <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />New Pump )(Pump Replacement I Pump Repair _ Raise Well Casina PAVM <br />Drilling Method - Mud Rotary L Air Rotary _j Auger U Cable Tool _ Push Point _ Other <br />Proposed Well Depth fl Excavation in diameter I i Open Bottom 1 I Gravel Pack;Gravel Size e r <br />J Conductor Casing in diameter f Conductor Casing Depth ft ,AN JOAuui <br />II <br />UNwHONri <br />Well Casing Diameter in Thickness Gauge;ASTM Sched I l Steel Plastic I Stainless Steel Other „LAuii ULi <br />Grout Seal Depth ft _ Neat Cement (94 Ib bag45- 10 gal water) _ Sand Cement sack mail gal water <br />I Bentonite (20% solids) I; Other <br />Grout Placement Method _ Pumped J Free Fall . Other L Retardant: Accelerator (name) <br />(PEDESTAL Installed By Driller Pump Contractor Other <br />-1 Concrete Pedestal -]Dimensions Width ft Length R Thick in - Christy Box 1 Stove Pipe <br />PUMP >(—Submersible _ Turbine Other HP 1 Pump Set 127 It Standing Water Level 120 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 />raA`-i.'R ADVANCE NOTICE REQUIRED FOR 11! SDCr`7l/'11llC PLEASE CALL (209"i <br />SIGNED, TrtLE CEO_ _ DATE 8i1 <br />U <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />Date Arca--/ r/ ( Employee ID# A <br />Date I SPECIAL Well Permit <br />Date I WAIVER Received <br />Date <br />Constructed Well Depth <br />IE <br />PE <br />Codes <br />SC Received Check#/ <br />Info B Cash <br />Amount Date <br />Remitted <br />Permit/ Invoice # <br />Service Request # <br />Well ID# <br />Ll 3 f? <br />177 9 .2-b,') <br />2 <br />EHO43-M W3L.1PUA'r' P=_RMIr <br />r <br />M <br />D <br />0 <br />0 <br />A <br />ED, <br />2021 <br />hiENr <br />