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164234 WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WERE,AVE 3"FL-STOCKTON CA 95202-(209)468-3420 NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR I NSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED y JOB ADDRESS _ j 3�iJ O /r. Thornton CITYIZIP Lodi _ s CROSS STREET APN C55-150-07 PARCELSME OWNER NAME Ray Coldani _ PHONE 369-5206 ' OWNERADDRESS 13199 X. Ray Road CITY/STATEiZiP Lodi. CA 95242 CONTRACTOR _Delta Stockton Pump PHONE 466-9625 CoNTRACTORADDRESS 646 S. California Street CITY/STATE(ZIP Stoct(.ton. CA 952.03 SUBCONTRACTOR__... PHONE SUBCONTRACTOR ADDRESS CITY/STATF./ZIP LICENSE ❑C-57 ILtC.6l 0 D-09 ❑Other NUMBER 724778 EXPIRATION DATE Ny V GEOGRAPHICAL.INFORMATION: Coordinates X Y Township Range Section INTENDED USE 13 Domesti c/Pri vote Irrigation/Agncultural 12 Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization C1 Public Water System Ird:trerem Dem a ager (stem ama C..Wt . a. .one N.ribe, TYPE OF WORK ❑New Well O Replacement Well ❑Well Alteration/Modification ❑Test Hole 13 Gther O Monitoring Weli(s)__ numberof rel6 p Soil Borings) camber otborityy O Ceotochnical._-_ ]ember orborinp ❑Well Destruction O,p Out-Of-Service Well ❑Out-Of-Service'Well Renewal ❑New Pum 13 Pump R (% Pump Pump Repair O Cross-Conrrection Repair WELL CONSTRUCTION Drilling Method O Mud Rotary ❑Air Rotary O Auger O Cable Tool Cl Push PDinL ❑(hhcr Proposed Well Depth ft Excavation in diameter O Open Bottom O Gravel Pack/Gravel Sia in diameter ❑Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter—in Thickness/Gauge/ASTM Sched O Steel O Plastic O Stainless Steel ❑Other Grout Seal Depth rt O Near Cement(94 Ib bag/S-IO gal water) ❑Sand Cement sack mix 17 gal water Bentonite(20%solids) ❑Manufacturer Spec%solids_% Name_ O Spas on File Cl Specs Submitted Groin Placement Method ❑Pumped ❑FTec Fall 0 Other ❑Retardant i Accelerator(name) __._....._.._ PEDESTAL Installed By O Driller ❑Pump Contractor ❑OLhcr ❑Concrete Pedestal Dimensions: Width_ ft Length_ft Thick in ❑Christy Box O Stove Pipe PUMP ❑Submersible ❑Turbine O Other HP Pump Set ft Standing Water Level ft WELL DESTRUCTION O Open Bottom O Gravel Pack ❑Uncased ❑Other Well Diameter to Total Depth ft Depth to Wate:._ft O Casing to be Perforated from ft to ft Sealing Material ❑Neat Cement(94 lb bag/S-10gal water) ❑Sand Cement_ rack mix/7 gal water ❑Bentonite Pellets ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name _... O Specs on File ❑Specs Submitted Placement Method Cl Pumped ❑Free Fall ❑Other O Complete with Mushroom Cap ft below grade ❑Complete to Existing Surface Pad I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MINI: M HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS—PLEASE CALL(209)953-7697 SIGNED TITLE CPO r] DAT 04/15/04 I 1 C lA N 1 N i DEPARTMENTUSEODILV J Application Accepted By. Date_ d Arm L-/ Y Employee IDN 42, Grout Inspection By Date_ ❑ SPECIAL Well Permit Pump Inspection By Date 11%44 ❑ WAIVER Received Destruction Inspection By Date r....._......., Constructed Well Depth it COMMENTS PE I SC ReceivedChee Amount Permit/ Codes Info B Cash Remitted Date Service Request it Invoice N Well IN oS4 11o03 `fad o 00 EHD 43-02-006 - MASTER WATER WELL PERMIT 12/6/2002