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I WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 <br />2512 <br />(209) 468-3420 <br />NUN-KEFUNDABLE PERMIT t ALL (LU`J) U04 -/0y/ FOR IN5PECTIUN5 tAt'IKtJ "I YEAR FROM DATE ISSUED <br />JOB ADDRESS 23014 E. Skiff Rd, CITY/Zip Escalon/95320 <br />CROSS STREET Temple Creek Rd. APN 207-1j60-02 PARCEL SIZE 79.0 LAND USE APPLICATION # <br />OWNER NAME Wagner Diary - Contact: Silvano rD iE?I?G� $ ,� �LNGr'' PHONE 209-401-2229 <br />OWNER ADDRESS 22176 E. Skiff Rd. CITY/STATE/ZIP Escalon/95320 <br />CONTRACTOR Delta Pump Inc. PHONE 209-466-9625 <br />CONTRACTOR ADDRESS 646 S California St, CITY/STATE/ZIP Stockton/95203 <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE C-57 X C-61 - D-09 1 Other <br />PHONE <br />CITY/STATE/ZIP <br />NUMBER 1055434 EXPIRATION DATE 7/31/2023 <br />DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) ❑ Arsenic (4393) <br />INTENDED USE ❑ Domestic/Private X Irrigation/Agricultural J Industrial 'i7 Water Quality Monitoring CI Soil Sampling/Characterization <br />❑ Public Water System <br />If different from Owner Water System Name Contact Name or Phone Number <br />TYPE OF WORK 1; New Well i Replacement Well ❑ Well Alteration/Modification r Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings Geotechnical # of borings <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal _ Cross -Connection Repair <br />❑ New Pump Pump Replacement XPump Repair Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method ❑ Mud Rotary Air Rotary I I Auger i I Cable Tool _I Push Point I ' Other <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom Gravel Pack/Gravel Size in diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched ❑ Steel i Plastic I Stainless Steel i i Other <br />Grout Seal Depth ft ❑ Neat Cement (94 Ib bag/5-10 gal water) _ Sand Cement sackTr <br />I i Bentonite (20% solids) _1 Other "m' ° k -D <br />Grout Placement Method E. Pumped ❑ Free Fall Other i Retardant / Accelerator (name) , -,- 1 <br />PEDESTAL Installed By Ci Driller ❑ Pump Contractor - Other <br />U Concrete Pedestal L1 Dimensions: Width ft Length ft Thick SAN JOAQUIN COUNIY <br />�in ❑ Christy Box I Stove Pipe FIEAt TM <br />QLPARINIENI <br />PUMP ❑ SUbmerSlbleX Turbine Other HP 60 Pump Set ft Standing Water Level ft <br />Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect to the following items: CPS <br />Coordinates, property lines, adjoining properties, water bodies or courses, drainage pattern, roads, existing wells, 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 />AIININIUNI 24 HOUR ADVA.7, CE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />7� DEPARTMENT USE ONLY <br />Application Accepted By ��`—G--L— Date ir—i A� <br />Grout Inspection B Date l� <br />Pump Inspection By Date <br />Soil Boring Inspection By Date <br />COMMENTS�,-,\ '�, IIsi <br />Area l�%C" Employee ID# '�`� 67 <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth <br />ft <br />rn <br />m <br />m <br />0 <br />0 <br />X <br />m <br />N <br />C0 <br />PE SC Received Check#/ <br />Codes Info By a <br />Amount <br />Remitted <br />Date Permit/ Invoice # Well ID# <br />Service Re uest# <br />EHD(+43-00I0,25/2021 I n( We] l/Pump Permu <br />