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T1WELL/ PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL.HEALTH DEPARTMENT 304 E WEBER AVE 3"D FL-STOCKTON CA 95202 -(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> H <br /> JOB ADDRESS 28501 N. Mackville Road CITY/ZIP - -�-'d.E.��S <br /> Cry v <br /> CROSS STREET Liberty Rd. APN OU/,_/Lt7 - U PARCEL SIZE LAND USE APPLICATION# <br /> OWNER NAME Nestor Enterprises PHONE K, <br /> OWNERADDRESS 13852 e. Peltier Rd. CITY/STATE/ZIP Ca Acampo, CA 95220 <br /> CONTRACTORPurviance Billers, Inc. PHONE 209-887-3554 <br /> CONTRACTOR ADDRESS P. 0. BOX 64 CITY/STATE/ZIP Linden, Ca 95236 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE W C-57 ❑C-61 ❑D-09 ❑Other NUMBER 377923 EXPIRATION DATE 7/31/07 <br /> GEOGRAPHICAL INFORMATION: Coordinates X V Township Range Section <br /> INTENDED USE ❑Dome tic/Private R Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Chatacterizetion <br /> ❑Public Water System <br /> Ifd,ff tfrom Owner: Water Syatc. .— Conwt Name or Phom Numr <br /> TYPE OF WORK W New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> ❑Monitoring Well(s) #of wells ❑Soil Boring(s) a ofbodng ❑Geotechnical a of boring <br /> ❑Out-Of--Service Well ❑Out-Of-Service Well Renewal Cl Cross-Connection Repair <br /> ❑New Pump ❑Pump Replacement Cl Pump Repair <br /> WELL CONSTRUCTION <br /> 01) <br /> Drilling Method W Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other N <br /> Proposed Well Depth 600 ft Excavation 22 in diameter IXOpen Bottom ❑Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter 16 in Thickness/Gauge/ASTM Sched .250 lXSteel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth 3 6 0 ft ❑Neat Cement(94 16 bag/S-/0 gal wa(er) nSand Cement 10.5 sack mix/7 gal water �. <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> [Grout Placement Method R Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other - <br /> ❑Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Plpe <br /> r <br /> PUMP ❑Submersible jet Turbine ❑Other HP Pump Set ft Standing Water Level ft � <br /> I HEREBY CERTIFY THAT 1 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 <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> ININIUNI Z4 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS G <br /> SIGNEDC�l /G� TITLE Corporate Secretary DATE 11 /1 /05 u <br /> Aul" <br /> I , <br /> 4 <br /> T <br /> DEPARTMENT USE <br /> /ONLY <br /> Application Accepted B LYrti Date / f't.0 Area <br /> Grout Insp n By Date l/�J <br /> Pump Ins Dated(/�Z! <br /> Constructed Well Depth �- It <br /> COMMENTS U c 0 LOT O F-4-E[.Q <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By Remitted Service Request# <br /> ��, /'f-t- aoTD 3.?s 2, ao� 200 <br />