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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3-FL-STOCKTON CA 95202 -(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JoswoDREss 28501 N Macky'l l ie Rel CrrY/ZIP Cl ements 95227 y <br /> 0 <br /> CROSS STREETLiberty APN jS0q-hPARCELSIZE3�_F­Q LAND USE APPLICATION# p <br /> OWNER NAME Nestor Rntarnri-;es PHONE_(209)727_5092 <br /> OWNER ADDRESS 13825 E. Peliter Rd CrrY/STATE/ZIP Acampo CA 95220 <br /> CONTRACTOR Purviance Drillers Inc PHONE(209)S87-3554 <br /> CONTRACTORADDRESS 17707 E Hwy 26 CITY/STATEJZIPLindpn., ra Q57'36 <br /> SUBCONTRACTOR PHONE _ <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ®C-57 ❑C-61 ❑D-09 ❑Other NUMBER 3 73 7�-3_ EXPIRATION DATE_Q 7-3 1-07 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE I$Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> If ddfc mt from Ow : Conwt Name or Phom Numb- <br /> TYPE <br /> um rTYPE OF WoRK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> ❑Monitoring Welts #of wells ❑Soil Borin s x orborings :1 Geotechnical w ofborinp <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ❑New Pump N Pump Replacement ❑Pump Repair <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth It 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 Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth ft ❑Neal Cement(94 1h bag/5-10 gal water) ❑Sand Cement sack mix/7 gal water <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids_% Name ❑Specs on File 13Specs Submitted <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTA Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> ❑Concrete Pedestal Dimensions:Width R Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> MP pJ Submersible 13 Turbine ❑Other HP1 2 Pump Set 278 ft Standing Water Level 12 9 ft <br /> 1 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 I AM IN COMPLIANCE WITH ALL <br /> WORKERS COM PEN �ONLAWS. <br /> INIMUNI 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGN 6? � TITLE Corporate Secretary DATE_ <br /> /24/06 <br /> Ir ;l <br /> EP IRT ENT SE NLY <br /> ` fqj <br /> Application Accepted Bye _ Date Area Employee ID#� <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection B Date ❑ WAIVER Received <br /> Constructed Well Depth ft <br /> COMMENTS Lltl qw, <br /> PE -S8C Received Check#, Amount Date Permit/ Invoice# Well IDN <br /> Codes Info B ash Remitted Service R uest# <br /> 1 z_S 00qWW <br />