Laserfiche WebLink
I <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />IvvIN-KEFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 24305 E. State Route 4 .., .._ _ _ CITY/ZIP Farmington/95230 <br />CROSS STREET Escalon-Bellota Rd. APN 187-05-017 PARCEL SIZE 29.25 LAND USE APPLICATION # <br />OWNER NAME Jim Boone _ PHONE 209-886-5490 <br />OWNER ADDRESS SAME CITY/STATE/ZIP <br />CONTRACTOR _Delta_ Puma Inc.___ PHONE 209-466-%25 <br />CONTRACTOR ADDRESS 646 S. California St. _ CITYISTATEMP Stockton/95203 <br />SUBCONTRACTORICONSULTANT PHONE <br />SUBCONTRACTORICONSULTANT ADDRESS CITYISTATEIZIP <br />LICENSE 1 C-5? X C-61 D-09 -- Other NUMBER 1055434 EXPIRATION DATE 7131/2021 <br />BILLING PARTY: OWNER CONTRACTOR 11 SUBCONTRACTORICONSULTANT <br />DOMESTIC WELL SAMPLING: -1 General MmeralJCollform Bacteria (4391) -1 Dibromochloropropane (4392) -1 Arsenic (4393) <br />INTENDED USE -1 Domestic: Private X IrrigationiAgricultural - Industrial -1 Water Quality Monitoring f Soil Sampling%Characterization <br />I Public Water System <br />If different from Owren Water System Name Contact Name or Phone Number <br />TYPE OF WORK <br />: I New Well I Replacement Well Well Altera tioniModification <br />Other <br />(� <br />G I <br />O-; <br />Monitoring Well(s) # of :vclls - Soil Borings) <br />3 F Geotechnical <br />I Out -Of -Service Well Out -0f -Service Well Renewal <br />Cross -Connection Repair <br />v C j VC� <br />VE <br />Nerl Pum fir, Pum Replacement I Pum Re air <br />Raise Well Casing <br />WELL CONSTRUCTION <br />MAY n 7 <br />Dnlhng Method <br />_j Mud Rotary L Air Rotary a Auger U Cable Tool Push Point <br />_ Other <br />2021 <br />GA <br />Proposed Well <br />Depth ft Excavation in diameter I I Open Bottom i I Gravel PackiGravel'SizeFNrl„'gQU <br />IV <br />N DO,8� <br />J Conductor Casingin diameter 1 Conductor Casing Depth <br />It <br />HEALTH p ENTAL. <br />EFARTMEN <br />Well Casing <br />Diameter _ in Thickness Gauge;ASTM Sched I i Steel <br />Plastic I Stainless Steel <br />Other <br />Grout Seal <br />Depth ft _ Neat Cement (941b bag/5- 10 gaf water) _ <br />Sand Cement <br />sack rrux17 gal water <br />I Bentonite (20% solids) I Other <br />Grout Placement <br />Method _ Pumped U Free Fall _ Other L Retardant <br />i Accelerator (name) <br />(PEDESTAL Installed By Driller - Pump Contractor Other <br />-1 Concrete Pedestal ']Dimensions Width It Length R Thick in - Christy Box n Stove Pipe <br />PVMP XSUbmerslble_ Turbine Other HP.3O Pump Set 212 tt Standing Water Level 125 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 />SIGNED �_,L)VANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />TITLE CEO DATE 55/21/2021 <br />/ DEPARTMENT USE ONLY <br />Application Accepted By Z, Date Sol 4d <br />Grout Inspection By <br />Pump Inspection By ate 2 <br />Soil Boring Inspection By Date <br />COMMENTS <br />Area Employee ID# <br />I SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth <br />PE <br />Codes <br />SC <br />Info <br />Received he Amount Date Permit/ Invoice# WellID# <br />B Cash Remitted I I Service Request # <br />(� <br />G I <br />O-; <br />c <br />EH0 43-06 6111rMI9 WELL!PUMP PERMIT <br />WI <br />M <br />D <br />v <br />0 <br />A <br />�N <br />