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1 WELL/PUMP PERMIT 2475 <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 />JOB ADDRESS 10855 Van Allen Rd. CITY/ZIP Stockton/95215 <br />CROSS STREET Skiff Rd. APN2.05-15-010 PARCEL SIZE 1 24.5 LAND USE APPLICATION # <br />OWNER NAME Dykxhoorn Farms - Contact: Rick % D i,k PHONE 209-838-2668 <br />OWNER ADDRESS 10774 S. Carrolton Rd. CITYISTATEIZIP 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 PHONE <br />SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br />LICENSE C-57 X C-671 D-09 O!her NUMBER 1055434 EXPIRATION DATE 7/31/2023 <br />DOMESTIC WELL SAMPLING: D General Mineral/Coliform Bacteria (4391) D Dlbromochlorepropane (4392) D Arsenic (4393) <br />INTENDED USE X Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring : Soil Sampling/CharacterizatiotP <br />Public Water System e_ <br />If different from Owner Ala'er System Name Contact Name or Phone Number rXr 7, <br />TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br />1 Monitoring Well(s) # of wells Soil Boring(s) "0' FO"" ;S Geotechnical z of r� r� <br />Out -O( -Service Well Out -Of -Service Well Renewal Cross -Connection Repair S (j x <br />New Pump X Pump Replacement PumpRepair Raise Well Casino <br />WELL CONSTRUCTION NSA V I HO—,I V ("G <br />Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other N DFp4R T <br />Proposed Well Depth It Excavation in diameter D Open Bottom Gravel Pack/Gravel Size in diamete <br />Conductor Casing in diameter ! Conductor Casing Depth ft <br />Well Casing Diameter _ In Thick ness/Ga uge/ASTM Sched r! Steel Plastic Stainless Steel Other <br />Grout Seal Depth ft Neat Cement (94 Ib bag/5-10 gat seater) Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method Pumped Free Fall Other Retardant / Accelerator (name) <br />'PEDESTAL Installed By Duller Pump Contractor Other <br />Concrete Pedestal Dimensions Width ft Length ft Thick <br />LIn Christy Box Stove Pipe <br />PUMP X Submersible Turbine Other HP 5 Pump Set 160 ft Standing'vVater Level 100 ft <br />Plot Plan Requirements: :attach a plot plain with the enact location of water hell with respect to the following itenis: CPS <br />Coordinates, propert* lines, adjoining properties, hater bodies or courses. drain:t<_,e pattern, roads. existing wells, structures. <br />potential sources of contamination. Sellers or pl-kate disposal systems. lnclnde dishince from tiio property lines. For Domestic. <br />,,'riculture. Industrial well, provide location of any water lectin or surface water iiithiu 200' radius of proposed hell. <br />`SII\1x11 xl?a ll(II N ADv1\('E \OI If'P 14101 IRFD I•()R INSPIf'( 11IONS-11LI.,kSl ( II I f21119)943-7691 <br />DEPARTMENT USE ONLY <br />Application Accepted By Date �� .� Area q �if C Employee ID# A G <br />Grout Inspection B <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />Date SPECIAL Well Permit <br />Date\, WAIVER Received <br />Date <br />Constructed Well Depth <br />ft <br />m <br />D <br />O <br />O <br />rn <br />N <br />j PE <br />Codes <br />Sc Received h <br />Info B Cash <br />Amount <br />Remitted <br />Permit/ <br />Date Service Re uest # Invoice # Well ID# <br />4 SI <br />o5D <br />I <br />I linPu-rM 10:5 2021 I'ayc- 1 , = \Pct! I'uary, I'o mn <br />