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1 WELL/PUMP PERMIT 5148 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1666 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)465-3420 <br /> NON-REFYNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> VJ <br /> JOB ADDRESS Escalon-Bellota Rd. cITY/zIP Farmington/95230 m <br /> pD <br /> CROSS STREETHwy 4 APN 18720026 PARCEL SIZE 20.34 LAND USE APPLICATION# S <br /> fn <br /> OWNER NAME Les Stroian PHONE 209-985-5346 uNi <br /> OWNER ADDRESS PO Box 141 CITY/STATE/ZIP Farmington/CA/95230 <br /> CONTRACTOR Delta Pump Inc. PHONE 209-466-9625 <br /> CONTRACTOR ADDRESS PO Box 702 CITY/STATE/ZIP Linden, CA 95236 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ❑ C-57 X C-61 ❑ D-09 ❑ Other NUMBER 1055434 EXPIRATION DATE 7/31/2027 <br /> DOMESTIC WELL SAMPLING:. General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE ❑ Domestic/Private X Irrigation/Agricultural ❑ Industrial ❑ 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 ❑ New Well ❑ Replacement Well ❑Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotech ,��_I�1° Y <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal 11 Cross-Connection Re �jl V/riL <br /> ❑ New Pump ❑ Pump Replacement XPump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION SEP 2 92015 <br /> Drilling Method ❑ Mud Rotary 11 Air Rotary ❑ Auger 11 Cable Tool ❑ Push Point El Other <br /> Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameteJl;. <br /> l� <br /> ElConductor Casing in diameter / Conductor Casing Depth fVN V I RON N1 EN H EALti� <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless$WPt%, <br /> Grout Seal Depth ft ❑ Neat Cement(94/b bagl5-10 gal water) ❑ Sand Cement sack mix17 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal❑Dimensions:Width ft Length ft Thick <br /> �in ❑ Christy Box ❑ Stove Pipe <br /> PUMP ❑ Submersibles(Turbine ❑ Other HP 40 Pump Set 180 ft Standing Water Level 143 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 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 /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By �tom-- Date Z Area Employee ID# <br /> Grout Inspection By Date r n 7 SPECIAL Well Permit <br /> Pump Inspection By ate ul ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received1 Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Cash Remitted Service Re uest# <br /> errLfp 0► 2sLk <br /> 25m 11�C� <br /> Z- I RECEIVED <br /> eHDo43-0604i07i2022 <br /> Uploaded f into Acce l a SAN JOAQUIN COUNTY" <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br />