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OWNERNAME v Frank Stonebarger PHONE <br /> OWNER ADDRESS CITY/STATE/LIP 8408 N. Beecher Rd. � <br /> Stockton CA 95215 <br /> CONTRACTOR Purviance Drillers, Inc. PHONE 209-887 X54 <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> SUBCONTRACTOR PHONE <br /> ' SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE 9 C-57 ❑C-61 ❑D-09 ❑Other NUMBER 377923 EXPIRATION DATE 7 31 0 7 <br /> I <br /> ' GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Owner Water System Name Contact Name or Phone Number <br /> h <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> ❑Monitoring Well(s) #of wells ❑Soil Boring(s) s o£borings ❑Geotechnical of borings <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ' ❑New Punip GE 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 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 ❑Neat Cement(94 lb hag/5-10 gal water) ❑Sand Cement sack mix!7 gal water <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> ' Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Acceierator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> ' ❑Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP jil Submersible ❑Turbine ❑Other HP 3 Pump Set 16 8 ft Standing Water Level 12 6 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 <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> NIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNE TITLE Corporate Secretary DATE 8/24/06 <br /> v j �• <br /> J <br /> '�Z! <br /> ' D A TMENT USE LY <br /> Y /1 <br /> Application Accepted By Date (5 Area Employee ID#Cl&)io (� <br /> ' Grout Inspection By Date 13SPECIAL Well Permit <br /> Pump Inspection B Date ❑ WAIVER Received <br /> Constructed Well Depth-71 <br /> ,+it <br /> ' COMMENTS <br />