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#6780 WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3m FL-STOCKTON CA 9$202 -(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 r()R I1,sPe.cTION'S EXPIRES 1 YEAR FROM DATE ISSUED J <br /> JOB ADDRESS Kingdon Road ��-/� N �Gf/�Zlllf)'!/�TY/ZIP Lodi <br /> b <br /> CROSS STREET Thornton APN 055-150-07 PARCELSIZELL�/ AND USE APPLICATION# Z <br /> n <br /> OWNER NAME Ray Coldani PHONE 369-5206 <br /> OWNERADDRESS 13199 N Ray Road CITY/STATEIZIP Lodi CA 95242 1, <br /> CONTRACTOR Delta Pump PHONE 466-9625 ,\ <br /> CONTRACTOR ADDRESS 646 S. California Street CITYISTATE17JP Stockton CA 95203Le <br /> PHONE ' <br /> SUBCONTRACTOR <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP 1 <br /> LICENSE ❑C•57 ffC•61 ❑D-09 ❑Other NUMBER 724778 EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township— Range Section— <br /> uon/Agnculturdl ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> INTENDED USE ❑Domestic/Private [MrrrgaA <br /> ❑Public Water System e \V{I <br /> If different from Owner. aar system ame onlay arra or um r <br /> TYPF.OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other a of horings <br /> ❑Monitoring Wells) #of wells ❑Soil Boring(S) °of Inns` [I Geotechnical <br /> ❑Out-Of--Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ❑New Pum (X.Pump Replacement ❑Pump Repair <br /> WELL,CONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Sizein diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in ThickncWGauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other r <br /> Grout Seal Depth ft ❑Neat Cement(941b bag/S-JO gal water) ❑Sand Cement sack mix/7 gal water <br /> ❑Bentonite(209/o solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method O Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> ❑Concrete Pedestal Dimensions:Width ft Length ftThick n ❑Christy Box 13 Stove Pipe <br /> PGMP E Submersible ❑Turbine ❑Ocher HP 15 Pump Set 4 2 ft Standing Water Level 10 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 I <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL I <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED TITLE CEO DATEWill <br /> 04/28/06 <br /> C <br /> �7#7_1- <br /> NV R <br /> D P A R T M E N T USE ONLY <br /> Application Accepted ByDau Area Employ-ID# <br /> Grout Inspection By to / ❑ SPECIAL Well Permit <br /> Pump Inspection ByC <br /> - 'Date �> -1 ❑ WAIVER Received <br /> Constructed Well Depth <br /> ft <br /> COMMENTS <br /> PE SC Received Cbeck# Amount Date Permit/ Invoice# WellID# <br /> Codes Info B ash Remitted Service Re uest# <br /> 13s so. L0N <br /> WELL PUMP PERMIT <br /> END 4107.006 <br /> ImnOos <br />