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1 WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> N <br /> JOB ADDRESS 22331 E. Skiff Rd. CITY/ZIP EScalon, CA 95320 m <br /> E. e Creek -19-003 60.09 D <br /> CROSS STREET Eof TemlCk RdAPN 205 P PARCEL SIZE LAND USE APPLICATION# z <br /> M <br /> OWNER NAME Wagner Land CO. PHONE 209-652-5099 y <br /> OWNER ADDRESS 22176 Skiff Rd. CITY/STATE/ZIP Escalon, CA 95320 <br /> CONTRACTOR Hennings Bros. Drilling Co., Inc. PHONE 209-545-1185 <br /> CONTRACTOR ADDRESS 1930 Ladd Rd. CITY/STATE/ZIP Modesto, CA 95356 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATE/ZIP <br /> LICENSE X C-57 C-61 D-09 Other NUMBER 290813 EXPIRATION DATE 5-31-24 <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic(4393) <br /> INTENDED USE X Domestic/Private Irrigation/Agricultural 1-1 Industrial C: Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK X New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> Monitoring Well(s) #of wells ❑ Soil Bonng(s) #of borings i: Geotechnical #of borings <br /> Out-Of-Service Well ❑ Out-Of-Service Well Renewal _I Cross-Connection Repair <br /> New_Pump Pump Replacement ❑ Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method X Mud Rotary ❑ Air Rotary ' Auger i I Cable Tool Push Point IJ Other <br /> Proposed Well Depth 300 ft Excavation 12 in diameter Open Bottom X Gravel Pack/Gravel Size no, in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth_ ft <br /> Well Casing Diameter 6 in Thickness/Gauge/ASTM Sched SDR21 Steel X Plastic Stainless Steel -. Other <br /> Grout Seal Depth 200 ft ❑ Neat Cement(94/b bag/5-10 gal water) - Sand Cement sack mix/7 gal water <br /> X Bentonite(20%solids) ❑ Other PAYMENT <br /> Grout Placement Method X Pumped ❑ Free Fall Other G Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller X Pump Contractor ❑ Other <br /> Concrete Pedestal❑Dimensions:Width ft Length ft Thick e 9 D 2027 <br /> in ❑ Christy Box ❑ Stove Pipe <br /> PUMP ❑ <br /> Submersible[] Turbine ❑ Other HP Pump Set ft Standing WatdD&Nb4PAQUI <br /> Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect tothe foil � A PSN <br /> Coordinates, property lines, adjoining properties, water bodies or courses, drainage pattern, roads, existing we Is, structures, <br /> potential sources of contamination, sewers or private disposal systems. Include distance from two property lines. For Domestic, <br /> Agriculture,Industrial well,provide location of any water wells or surface water within 200' radius of proposed well. <br /> MINIMUNI 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> P A T M E N T S E N L Y <br /> 7 <br /> Application Accepted By f / Date G �w Area Employee ID# <br /> Grout Inspection By Date \fit J�rON�, PECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil BorincLjnspection By {� Date Constructed Well Depth ft <br /> COMMENTS I \ZI) <br /> PE SC Received Check#/ Amount Permit/ <br /> Codes Info Cash Re itted Date ervice Request# Invoice# Well ID# <br /> -I, 2n 1-211 ZZ VO 55 <br /> Gr U 7 <br /> L LAS <br /> EIII)043-06 10/25/2021 r/'� �,�JPage 1 or'- Well i Pump I'crmn <br />