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I <br />15� WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />NON-REFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 13950 N. Thornton Rd CITYIZIP Lodi/95242 <br />CROSS STREET W. Kingdon Rd. APN 055-14-021 PARCEL SIZE.LAND USE APPLICATION # <br />OWNER NAME Colpdpani Farms - Steve Coldani PHONE 209-421-6121 <br />OVIJNER ADDRESS _SAME CITY/STATE/ZIP <br />CONTRACTOR Delta Pump Inc PHONE 209-466-9625 <br />CONTRACTOR ADDRESS 646 S. California St. CITY/STATE/ZIP Stockton/95203 <br />SUBCONTRACTORICONSULTANT_ PHONE <br />SUBCONTRACTORICONSULTANT ADDRESS CITYISTATE/ZIP <br />LICENSE iC `" X C-61 D-09 Other NUMBER 1055434 EXPIRATION DATE 713112021 <br />BILLING PARTY: OWNER CONTRACTOR I I SUBCONTRACTORICONSULTANT <br />DOMESTIC WELL SAMPLING: -1 General Mineral/Coliform Bacteria (4391) -1 Dibromochloropropane (4392) -1 Arsenic (4393) <br />INTENDED USE Domestic!Private X IrrigationiAgricultural - Industrial - Water Quality Monitoring r' Soil Sampling.+'Characterization <br />Public Water System <br />f di'ferent from Owrei. Water Systern Name Contact Name or Phone Number <br />TYPE OF WORK <br />I New Well I Replacement Well Well Alteration./Modification Other <br />Date Permit/ <br />I Service Request # <br />Invoice # Well ID# <br />-1 Monitoring Well(s) it of wells - Soil Boring(s) A of borings F Geotechnical <br />of 04 „ �/n ,• <br />21 ,LIZ <br />I Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair� <br />I New Pum I- Pum Replacement Pum Repair Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method <br />Mud Rotary L Air Rotary U Auger U Cable Tool _ Push Point _ Other <br />hIAY % <br />Proposed Well <br />Depth R Excavation in diameter I I Open Bottom I Gravel Pack.Gravel Size S JOQ otliarneter <br />Conductor Casing in diameter ! Conductor Casing Depth it 14E <br />IRON <br />Well Casing <br />BOO <br />Diameter _ in Thick ness`GaugeiASTM Sched I I Steel Plastic I Stainless Steel OtherLrN �EPARTne j <br />Grout Seal <br />Depth it _ Neat Cement (94 !b bag/5- 10 gal water) _ Sand Cement <br />sack mrx.-7 gal water <br />I Bentonite (20% solids) i Other <br />Grout Placement Method _ Pumped U Free Fall - Other L Retardant! Accelerator (name) <br />PEDESTAL <br />Installed By Driller Pump Contractor - Other <br />-1 Concrete Pedestal ']Dimensions Width ft Length ft Thick in Christy Box <br />�l Stove Pipe <br />PUMP <br />X Submersible- Turbine Other HP Pump Set it Standing Water Level ft <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />Application Accepted By Dale S i7 d Area�G Employee IDSNA1 <br />Grout Inspection By 4 Date I SPECIAL Well Permit <br />Pump Inspection By Date Z I WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth it <br />COMMENTS <br />W <br />M <br />A <br />0 <br />A <br />m <br />1 <br />PE <br />Codes <br />Sc Received Chee Amount <br />Info By Cash Remitted <br />Date Permit/ <br />I Service Request # <br />Invoice # Well ID# <br />S D %7Io <br />21 ,LIZ <br />EHD 43-0C Gfl V�019 <br />WELL /PUMP PERMIT <br />ry <br />