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#6780 WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3°a FL-STOCKTON CA 95202-(209)466-3420 <br /> NON-REFUNDABLE PERMIT ��//��CALL 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS Kingdon Road !'"j—SV N � �lDt/ CITY/zip Lodi <br /> v <br /> CROSS STREET Thornton APN 055-150-07 PARCEL SIZE////. o/1 LAND USE APPLICATION# m <br /> OwNERNAME Ray Coldani PHONE 369-5206 " <br /> OWNER ADDRESS 13199 N. Ray Road CrrY/STATEJZIP Lodi CA 95242 _ <br /> CONTRACTOR Delta Pump PHONE 466-9625 <br /> CONTRACTOR ADDRESS 646 S. California Street CITY/STATE/ZIP Stockton, CA 95203 __ iV, <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS Cn Y/STATF/ZIP <br /> LICENSE ❑C-57 C.C-61 ❑D-09 ❑Other NUMBER 724778 EXPIRATION DATE �\ <br /> GEOGRAPHICAL INFORMATION'. Coordinates X Y Township_ Range SecUDn— <br /> INTENDED USE ❑Domesucftvate [Xirrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> IfdiOe <br /> cera System are onract ame or um <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> 13Monitoring Wells) #of wells [3Soil Boring(s) #ofaoaop 13Geotechnical a ofborings <br /> ❑Out-of--Service Well E3Out-Of-ServiceWell Renewal 13 Cross-Connection Repair <br /> 13 New Pum 1XPum 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 Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schell [3Steel [3 Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth ft ❑Neat Cement(941h bag/5-10 gal wafer) ❑Sand Cement sack mix 17 gal water <br /> ❑Bentonite(20°/solids) ❑Manufacturer Spec%solids_% Name ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESPAL Installed By ❑Driller ❑Pump Contractor ❑ OtherI <br /> ❑Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑Christy Bos [3 Stove Pipe <br /> PUMP ID Submersible ❑Turbine ❑Other HP15 Pump Set 47 ft Standing Water Level 10 ft <br /> 1 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. f ALSO CERTIFY THAT MY REQUIRED LICENSE IS I <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> NIINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED TITLE CEG DATE 04/28/06 <br /> INC <br /> NV H <br /> PARTMENT USE ONLY <br /> Application Accepted By \ t D : Date Area Employee ID# T(J <br /> Grout Inspection By ate ❑ SPECIAL Well Permit <br /> Pump Inspection By ,? % SDate C ❑ WAIVER Received <br /> Constructed Well Depth ft <br /> COMMENTS lG -G l //j7`C �/:'�1. --T.G<TE=C«L r/lr l'' � k2 V��'-� �y1 -kZ LIQ J <br /> PE SC Received Check# Amount Pe mi Invoice# Well ID# <br /> Codes Info B ash Remitted Date Service R uest# <br /> !35 <br /> W ELL PUMP PERMIT <br /> EHD43-02-006 <br /> 1/2712005 <br />