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Ir <br /> 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 /> JOB ADDRESS 4196 S. Escalon Bellota Rd. CITYIZIP Farmington/95230 m <br /> D <br /> CROSS STREET Hwy 4 APN 18720004 PARCEL SIZE 20.12 LAND USE APPLICATION# A <br /> M <br /> OWNER NAME Les Stroian _ PHONE 209-985-5346 y <br /> OWNER ADDRESS PO Box 141 CITYISTATE/ZIP Farmington/CA/95230 <br /> CViJTRiaCTOR 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 I C-57 X C-61 I D-09 ❑ Other NUMBER 1055434 EXPIRATION DATE 7/31/2027 <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (43911 Dibromochlorooropane(4392) Arsenic(4393) <br /> INTENDED USE ❑ Domestic/Private X Irrigation/Agricultural 11 Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> ❑ Public Water System <br /> If a f elerd i ccn Gwrwr. ..mai SySizrr;if'4&me ccwitz.:Nwr'Be w rfiiGrrc l gybes <br /> TYPE OF WORK ❑ New Well Replacement Well ❑ Well Alteration/Modification I; Other <br /> rl 1 i.-, Ne l(s) 31:of�n llc n Coil Pn in 10 #of borings r1 r #of borings <br /> M7f}1.4r.f�� I�.� . . _.. �At2/..�3r?U12� <br /> ❑ Out-Of-Service Well 11 Out-Of-Service Well Renewal L. Cross-Connection Repair JUL <br /> 11 New Pump [I Pump Replacement X Pump Repair I! Raise Well Casing <br /> �W28 20 <br /> ELL CoNsTRirrora ) <br /> Drilling Method I1 Mud Rotary 11 Air Rotary n Auger 11 Cable Tool Push Point a Other LNC �FZON111E <br /> Proposed Well Depth ft Excavation in diameter n Open Bottom ❑ Gravel Pack/Gravel PA <br /> L; Conductor Casing in diameter / Conductor Casing Depth ft 1%1 <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched ❑ Steel I1 Plastic I 1 Stainless Steel r7 Other <br /> Grout Seal Depth ft ❑ Neat Cement(94 Ib bagl5-10 gal water) 17 Sand Cement sa :U1 <br /> ❑ Bentonite(20%solids) Li Other <br /> Grout Placement Method Li Pumped ❑ Free Fall ❑ Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By i.! Driller ❑ Pump Contractor ❑ Other <br /> Concrete Pedestal❑Dimensions:Width ft Length ft Thick <br /> �in ❑ Christy Box ❑ Stove Pipe <br /> PUMP i Submersible 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 IIOUR ADN'%NCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALI.(2119)953-769- <br /> DEPARTMENT USE ONLY <br /> Application Accepted By�. Date 7 -7/ Area Employee ID# <br /> Grout hispecfion By Date rn SPECIAL Well Permit <br /> Pump Inspection By ate W L WAIVER Received <br /> Soil Boring!nspccticn By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received CCh—ecUp Amount Date Permit/ Invoice# Well ID <br /> Codes Info B Remitted Service Re uest# <br /> O d 2-5 AP25m2y (7�2. <br /> VU 1� <br /> EHD043-0604/07/2022 Page I or'_ Uploaded into cce ael[.PumPPerms <br />