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#4234 WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3"a FL-STOCKTON CA 95202-(209)465-3420 NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR I NSPECTIONS. EXPIRES 1 YEAR FROM DATE ISSUED P Joe ADDRESS _ / 3 fro /u Thornton CITYIZIP Lodi _ y CROSS STREET APN 055-150-07 PARCELSITE lJ OwNERNAMt Ray Coldani PHONE 369-5206 OWNERADDRESS 13199 N. Ray Road CrrY/STATER,, Lodi, CA 95242 _ CONTRACTOR Delta Stockton Pump PHONE 466-9625 CONrRA<.TORADDREss 646 S. California Street CITY/STATE/ZIP Stockton, CA 95203 SUBCONTRACTOR PHONE W SUBCoNTRAcrOR A DURESS _ CITY/STATFJZ.IP LICENSE O C-57 130.61 0 D-09 ❑Other NUMBER 724778 EXPIRATION DATE GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE ❑Domestic/Privace. Irrigation/Agricultural ❑Industrial ❑Witter Quality Monitoring 03oi1Sampling/Characleriradon O Public Water System _ lydif mm tam Owner.�— amt biiia ante Domer ane or nage um TYPE OF WORK O New Well O Replacement Well 0 Well Alle-mrion/Modification ❑Test Hole O Other number of wroth number of t,06.P number of borinpr O Monitoring Wells) O Soil Borings) O C;eoteehnical _ 0 Well Destruction 0 Out-Of-Service Well ❑Out-Of-Service'Well Renewal 0 New Pump 0 Pump Rep;acement (SPump Repair ❑Cross-Connection Repair WELL CONSTRUCTION Drilling Method 0 Mud Rotary ❑Air Rotary 0 Auger O Cable Tool O Push POinL ❑Other Proposed Well Depth fl Excavation in diameter O Open Bottom 0 Gravel Pack/Gravel Sine in diameter 0 Conductor Casing in diameter / Conductor Casing Depth —ft Well Casing Diameter_in Thickness/Gauge/AS'M Sched ❑Steel O Plastic O Stainless Steel 0 Other Grout Seal Depth R O Neat Cement(941b bag/5.10gal"ter) 0 Sand Cement tuck mix 17 Sal water 0 Bentonite,(20%solids) 0 Manufacturer Spec%solids_% Name O Specs on File 0 Spccs Submitt*d Grout Placement Method 0 Pumped 0 Free Fall 0 Other_ O Retardant 1 Accelerator(name) —_— PEDESTAL Installed By O Driller 0 Pump Con tractor 0O:her ❑Concrete Pedestal Dimensions: Width_ft Length ft Thick in 0 Christy Box Cl Stove Pipe PUMP O Submersible 0 Turbine O Other HP Pump Set ft Standing Water Lcvcl ft WELL DESTRUCTION O Open Bottom Cl Gravel Pack 0 Uncased 0 Other Well Diameter in Total Depth - ft Depth to Water fl O Casing to be Perforated from ft to it Sealing Material Cl Neat Cement(94 Ib bag/5.10 gal water) 0 Sand Cement .tacit mit 17 gal water 0 Bentonite Pellets 0 Bentonite(200/solids) 0 Manufacturer Spec%solids_._% Namc -_ 0 Specs on File ❑Spees.Submitted Placement Method O Pumped ❑Free Fall 13 Other 0 Complete with Mushroom Cap ft below grade Cl Complete to Existing Surface Pad I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE LN 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 4 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS—PLEASE CALL(209)953.7697 SIGNED TITLE CFO _ DAor � P 11, C IP 1y Fi L- �i DEPARTMENT USE O LY Application Accepted By Date O Area� Employee 1Dk Grout Inspection By Datc ❑ SPECIAL Well Permit Pump Inspection ByDate [3WAIVERReceivel Destruction Inspection By Date Constructed Well Depth It COMMENTS PIE SC Received Ch Amount Permit/ Coda Into B Cash Remitted Dat` Service Rea rust IY Invoice p Well[Dp oS� ttoo3 `a`36 a EHO43-02-006 MASTER WATER WELL PERMIT 12/6/2002