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1 WELL/PUMP PERMIT 4931 <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 /> y <br /> JOB ADDRESS 4196 S. Escalon Bellota Rd. clTy/zIP Farmington/95230 m <br /> D <br /> CROSS STREET Hwy 4 APN 18720004 PARCEL SIZE 20.12 LAND USE APPLICATION# A <br /> M <br /> Cn <br /> OWNER NAME Les Strolan PHONE 209-985-5346 <br /> OWNER ADDRESS PO BOX 141 CITYISTATEIZIP Farmington/CA/95230 <br /> CONTRACTOR Delta Pump Inc. PHONE 209-466-9625 <br /> CONTRACTOR ADDRESS PO BOX 702 CITYISTATEIZIP Linden, CA 95236 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATE/ZIP <br /> LICENSE ❑ C-57 X C-61 ❑ D-09 ❑ Other NUMBER 1055434 EXPIRATION DATE 7/31/2027 <br /> DOMESTIC WELL SAMPLING:1 !General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392)i i Arsenic(4393) <br /> INTENDED USE ❑ DomesticlPrivate X Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> ❑ Public Water System <br /> If r4twoerd$i,rri Ovmer: .a*7 ay'S�-S'idle Conlacl Name 6t Pff-me hiL-t' <br /> TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> L,Mork}-orifi n Snii R—oring"s) #of borings n G-erotect-.il2t #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair JUL <br /> ❑ New Pum ❑ Pum Replacement X Pum Repair ❑ Raise Well CasingV <br /> WELL CONSTRUCTION <br /> Drilling Method ❑ Mud Rotary 11 Air Rotary 11 Auger 11 Cable Tool 11 Push Point 11 Other <br /> ENvIkoivnJE <br /> Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel 11WIVA <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft V <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth ft ❑ Neat Cement(94 Ib bagl5-10 gal water) ❑ Sand Cement saJU&F8g1i VI' <br /> ❑ Bentonite(20%solids) 11 Other <br /> ��L <br /> Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) QuIly f-_nu ll TV <br /> PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal[]Dimensions:Width ft Length ft Thick rr <br /> in ❑ Christy Box ❑ Stove Pipe <br /> PUMP ❑ SubmersibleX Turbine ❑ Other HP 40 Pump Set ft Standing Water Level 136 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)453-7697 <br /> DEPARTMENT USE ONLY <br /> Of <br /> Application Accepted By Date 7 Area / Employee ID# <br /> Grout Inspection By (Date ❑ SPECIAL Well PerM t <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Wett Depth t{. . <br /> COMMENTS <br /> PE SC Received eCTieck#0 Amount Date Permit/ Invoice# Well ID# <br /> Codes Info BY Remitted Service Re uest# <br /> p D 3\ zs ,AP25 M 2`-k 2 <br /> Wp <br /> EkID043-06 04/07/2022 Paye I of 2 O a e I n O ( -.c,A 'Jell/Pwnp Pet mit <br />