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CITYl2IP Linden, CA 9 5 2 3 6 PARCEL SIZE. GL3 7 7 OWNERNAME Kip Mellor ADDREss 16850 E. Fraizer Rd_ PQ C PHONE CONTRACTOR Purviance Drillers, Inc.ADDREss P.O.Box 64 CITY/Z Linden, Ca 95236 PH0NE209-887-3554 C-57 LICENSE#37797.3 EXP DATE__Zj 02 GEOGRAFMCAL INFORMATION: COORDINATES X_ Y_ TOWNSHIF RANGE SECTION ' TYPE OF WELL: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# 0 OTHER INSTALLATION: ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL# TYPE OF PUMP: ❑ NEW 0 REPAIR H.P. 1 10 DEPTH PUMP SET 1 III FT, FIRST WATER LEVEL ❑OUT-ORSERVICE WELL. ❑GEOTtECHNICAL# ❑SOIL BORING ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUC77ON SPECIFICATION ❑INDUSTRIAL 0 OPEN BOTTOM WELL EXCAVATION DCA CONDUCTOR CASING DIA IX DOMESTIC PRIVATE ❑GRAVEL PACK/SIZE WELL CASING TYPE WELL CASING DIA ❑PUBLIC/MUNICIPAL ❑•DRIVEN GROUT SEAL DEr- I SPECIFICATION IRRIGATION/AG OTHER GROUT BRAND NAME 0 MONITORING GROUT SEAL PUMPED: ❑YES ONO ❑CHRISTY BOX ❑STOVE PIPE CONCRETE PEDESTAL BY DRILLER: ❑YES ®NO APPROXIMATE WELL DEPTH PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION ANI')THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY C-57 LICENSE IS CURRENT AND ACTIVE WITH.THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKMAN'S p COMPENS kTION LAWS. �I UM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS ' SIGN E TITLE Cor orate Secretary _DATE1 116 02 i PIP e-4;1I �.. r f N1 LL Ll JA( A C(Ui"' F BLI HE I?i �F viu 1` DEPARTMENT USE ONLY Application Accepted.By Date EMPI # ' Grout Inspection B}. Date _Pump Inspected B _Date - Destruction Inspection By Date COMMENTS: