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#4234 WELL/ PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3"FL-STOCKTON CA 95202 -(209)468-3420 NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED v, H JOB ADDRESS _ / 3,17-5-0 /U Thornton CITY/ZIP Lodi _ CROSSSTREET APN 055-150-07 PARCELSIZE �_ un OWNER NAME Ray Coldani PHONE 369-5206 OWNER ADDRESS 13199 N. Ray Road CITY/STATE/ZlP Lodi, CA 95242 CONTRACTOR Delta Stockton Pump PHONE 466-9625 CONTRACTORADDRESS 646 S. California Street CITY/sTATEizir Stockton, CA 95203 SUBCONTRACTOR PHONE �y SUBCONTRACTOR ADDRESS CITYISTATFl7.IP LICENSE ❑C-57 diC-61 ❑D-09 ❑Other NUMBER 724778 EXPIRATION DATE 1 d GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section .yr INTENDED USE ❑Domestic/Private Y&Inigation/Agriculturxl ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Charaeterizadon ❑Public Water System Ir difremnt from r)wne.: aier htem ame ont-1 Name or Phone Number TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other ❑Monitoring Well(s)__ numberofrells 13 Soil Bon ng(s) number of borings ❑Ceolechnical numberofborinp ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of--Service Well Renewal ❑New Pump ❑Pump Replacement (ZPump Repair ❑Cross-Connecfion Repair WELL CONSTRUCTION Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Pom ❑Other Proposed Well Depth R Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter ❑Conductor Cuing in diameter / Conductor Casing Depth ft Well Casing Diameter_in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other Grout Seal Depth ft ❑Neat Cement(941b bug/5-10gu1 water) ❑Sand Cement suck mix/7 gal water ❑Bentonite(201/solids) ❑Manufacturer Spec%solids % Name ❑Spms on File ❑Specs Submitted Grout Placement Method LlPumped ❑Free Fall 13 Other- ❑Retardant/Accelerator(name) PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑Other ❑Concrete Pedestal Dimensions: Width ft LcngEh ft Thick in ❑Christy Box ❑Stove Pipe PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level R WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other Well Diameter in Total Depth ft Depth to Wale: R ❑Casing to be Perforated from ft to It Sealing Material ❑Neat Cement(941b bug/5-10gal Raster) ❑Sand Cement sack mix;7 gal water ❑Bentonite Pellets ❑Bentonite(20%solids) ❑Manufacturer Spec%solids__% Name ❑Specs on File ❑Specs Submitted Placement Method ❑Pumped ❑Free Fall ❑Other ❑Complete with Mushroom Cap ft below grade ❑Complete to Existing Surface Pad I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MINI: M 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953.7697 SIGNED - TITLE U0 DAT 04/15/04 P ark 1 c H ' DEPARTMENT USE O LY Application Accepted By - Date d Area }-/ Y Employee IDk Grout Inspection By Date / i —❑—SPECIAL Well Permit Pump Inspection By - Date V ❑ WAIVER Received Destruction Inspection By Date Constructed Well Depth __ h COMMENTS PE I SC Received Chec AmountPermit/ Codes Info By Cash Remitted Date Service Re ucst N Invoice# Well ID# a,5-,4 /1003 tf36 0 612 00