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OWNER ADDRESS 16930 Es Comstock Rd. CITY/STATE/ZIP Linden, Ca 95236 <br /> CONTRACTOR Purviance Drillers, Inc. PIIONE209-887-3S54 G <br /> CONTRACTOR ADDRESS P-D- LOX 64 CITY/STATEJZIP Linden, CA 95236 <br /> SUBCONTRACTOR n/a PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATEJZIP <br /> r LICENSE IAC-57 O C-61 , ❑D•09 ❑Other NUMBER 377923 EXPIRATION DATE7/3 0/0 3 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section !r <br /> � <br /> INTENDED USE [%Domestic/Private ❑Irrigation/Agricultural O Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Owner: ater System Name onwct ame or one um r <br /> TYPE OF WORK [NNew Well -❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other <br /> ❑Monitoring Well(s) number of wells ❑SoilBoring(s) numberofborinys 0Geotechnical number of borings <br /> ❑Well Destruction 0 Out-Of-Service Well O Out-Of-Service Well Renews! <br /> IN New Plimp °❑Pump Replacement ❑Pump Repair ❑Cross-Connection Repair <br /> WELL CONSTRUCTION <br /> Drilling Method [XMud Rotary 1 O Air Rotary ❑Auger O Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth 3001, ft Excavation 12 in diameter X Open Bottom O Gravel Pack/Gravel Size in diameter <br /> I ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter 6AB Thickness/Gauge/ASTM Sched a Steel ❑Plastic O Stainless Steel 12 Other <br /> Grout Seal Depth 2 0 0 rt ❑Neat Cement(941h hub/J-10gal water) IN Sand Cement 10.5 suck mix/7 gal water <br /> 17 Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs an File ❑Specs Submitted <br /> Grout Placement Method Cf Pumped O Free Fall ❑Other O Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor C3 Other <br /> ❑Concrete Pedestal Dimensions: Width ft Length fl Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP IXSubmersible il! ❑Turbine O Other HP 3 Pump Set 252 ti Standing Water Level tt <br /> f s WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack O Uncased O Other <br /> Well Diameter j1 in Total Depth ft Depth-to'Water tt ❑Casing to be Perforated from ti to ft <br /> Sealing Material ❑Neat Cement(941h hugl3-10 bat water) ❑Sand Cement suck mix/7 gal water ❑Bentonite Pellets <br /> O Bentonite(201/or'solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Placement Method O Pumped' ❑Free Fall O Other <br /> ❑'Complete with Mushroom Cap fl below grade ❑Complete to Existing Surface Pad <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. 1 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 COMPENSAT S. - <br /> NIUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> slGlve TITLE Corporate Secretary DATE 11 /18/02 <br /> rig <br /> Or <br /> tE nl <br /> P <br /> DEPARTMENT USE NLY <br /> AQPlicati-on Accepted By ^• -- Date ( "� a�-- Area 3 Employee lD#YU 5 <br /> o t <br /> �+ f Grout Inspection By Date 1 �SF�E IAL Weil PrVttl ��-; <br /> v 1 Pump Inspection By Date ❑ WAIVER Received <br /> bate Constru cd Well Depth ; ft <br /> Destruction Inspection By _ _ <br /> COMMENTS •Q d <br /> i6t*Wig <br /> S`ZJ P <br /> 3. r " <br /> PE SCAmount C Received Date Permit/ Invoice# Well ID# <br /> Codes Info Remitted ash By Service R uest# <br />