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11 <br />1 WELL/PUMP PERMIT 2486 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL (209) 953-7597 FOR INSPECTIONS LAI'IKL5 1 YEAR FROM UATE ISSUE[ <br />JOB ADDRESS 22331E Skiff Rd CITY/ZIP Escalon/95320 <br />CROSS STREET Temple Creek Rd. APN 205-190-03 PARCEL SIZE 60.09 LAND USE APPLICATION # <br />OWNER NAME Wagner Diary - Contact: Silyano PHONE 209-401-2229 <br />OWNERADDRESS 22176 E. Skiff Rd. CITYISTATE/ZIP Escalon/95320 <br />CONTRACTOR Delta Pump Inc. PHONE 209-466-9625 <br />CONTRACTOR ADDRESS 646 S California St CITY/STATEIZIP Stockton/95203 <br />SUBCONTRACTOR <br />ADDRESS <br />E . C-57 x C-61 ❑ D-09 ". Other <br />PHONE <br />CITYISTATEiZIP <br />NUMBER 1055434 EXPIRATION <br />DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) D Dibromochloropropane (4392) 0 Arsenic (4393) <br />INTENDED USE X DomesticlPrivate '_ Irrigation/Agricultural a Industrial Water Quality Monitoring 1 Soil Sampling/Characterization <br />Public Water System <br />If different from Owner. Water System Name Contact Name or Phone Number <br />TYPE OF WORK .J New Well Replacement Well o Well Alteration/Modification D Other <br />J Monitoring Well(s) # of wells D Soil Borings) z °f bOhings , Geotechnical u of bonngs <br />i Out -Of -Service Well D Out -Of -Service Well Renewal D Cross -Connection Repair <br />XNeW Pump �: Pump Replacement _.I Pump Repair ❑ Raise Well Casing <br />Drilling Method Mud Rotary - Air Rotary Auger Cable Tool Push Point Other <br />Proposed Well Depth ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter I Conductor Casing Depth It <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched . Steel D Plastic Stainless Steel Other <br />Grout Seal Depth ft Neat Cement (94 Ib bag/5-10 gal water) D Sand Cement sack m' <br />Bentonite (20% solids) Other <br />Grout Placement Method Pumped _ Free Fall Other Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor Other o <br />Concrete Pedestal Dimensions Width ft Length ft Thick sA" n.,uFNT <br />�in Christy Box Stove Pipe HEALTH DEPART <br />j uMP Submersible.- Turbine fi Other HP _1_,5__ Pump Set__2DO It 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: GPS <br />Coordinates, property lines, adjoining properties, water hodies 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 %%ells or surface water within 200' radius of proposed well. <br />\11 \1%11 NI 24 HO( I(,U)v 1�CF. *i0'f1('E NFOI IRF h trrN I I(INS - 11I1 \SE r' NI 1 (11144053-7697 <br />DEPARTMENT USE ONLY <br />or <br />Application Accepted By �� Z- Z— Date 3U . Area y Employee ID# P <br />Grout Inspection By Date ❑ SPECIAL Well Permit <br />Pump Inspection By Date\� ❑ WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth It <br />COMMENTS /(flew well eelynr- WPooy35ss- 939j Iy3�� ��ar+4lolrhs <br />m <br />m <br />D <br />0 <br />A <br />m <br />to <br />m <br />PE SC Received Check#/ <br />Codes Info B Ca§h <br />Amount Date <br />Remitted I <br />Permitl Invoice# Well ID# <br />Service Re uest # <br />a sl <br />s6 Z <br />P <br />EIID043.06 10+:5:2021 Ns. I of: WC11, Pump Pantu <br />