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vni�cn,�nmc OWNERADDRESS P. 0. BOX 3175'50 CITY/STATE/ZIP Stockton, Ca 95213 CONTRACTOR Purviarnce Drillers, Inc'. PHONE 209-887-3554 CONTRACTOR ADDRESS P•O•BOX 64 CITYISTATE/ZIP Linden, CA 95.236 I ' • SUBCONTRACTOR n/a Pltone SUBCONTRACTOR ADDRESS CITY/STATE/ZIP ,j LICENSE 1A C-57 ❑C-61:, ❑D-09 ❑Other NUMBER 377923 EXPIRATION DATE 7/03 M GEOGRAPHICAL INFORMATION: Coordinates X Y Township RangC Section INTENDED USE IR Domestic/Private ❑Irrigation/Agricuitural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization ❑Public Water System Ifdifferent from Owner: Water ysrem Name ontaaName or Ntonc Number ,.TYPE OF WORK !r4 New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other - ❑Monitoring Well(s) number ofwdis ❑Soil Boring(s) number ofborings ❑Geotechnical number ofborings •Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal I IN New Pump ❑Pump Replacement ❑Pump Repair ❑Cross-Connection Repair I WELL CONSTRUCTION Drilling Method 0 Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other Proposed Well Depth 400 ft Excavation 17 in diameter 10 Open Bottom ❑Gravel Pack/Gravet Size in diameter ❑Conductor Casing in diameter / Conductor Casing Depth ft i Well Casing Diameter 8 .62`lhickness/Gauge/ASTM Sched .156 N Steel ❑Plastic ❑Stainless Steel ❑Other i Grout Seat Depth 200 ft ❑Neal Cement(94 th hub/S-/0 gal water) IN Sand Cement 10.5 .rack in&/7 gal water ( ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑Other 1 ❑Concrete Pedestal Dimensions: Width ft Length ft Thick in D Christy Box ❑Stove Pipe -PUMP C4 Submersible II ❑Turbine ❑Other HP Pump Set_j_D 5 ft Standing Water Level ft WELL DESTRUCTION II Bottom ❑Gravel Pack ❑Uncased ❑Other ` Well Diameter in Total Depth Il Depth to Water R ❑Casing to be Perforated from ft to ft Sealing Material ❑Neat Cement(941h hug/S•10gal wetter) q Sand Cement suckmix/7 gal water ❑Bentonite Pellets ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Placement Method ❑Pumped ❑Free Fall ❑Other i ❑Complete with Mushroom Cap ft below grade ❑Complete to Existing Surface Pad 1 HEREBY CERTIFY THAT I IHAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN I JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL i WORKERS COMPENSATION i M 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS SIGNED / TITLE Corporate Secretary DATE1 0/1 0/0 2 i get I i n DEPARTMENT UY t:,s �Application�AEcepted_8ys Date 0=i_ _ Area 2l Employee IDa t Grout Inspection By Date "" -❑ SPECIAI:Well el 1111t~ Pump Inspection By Date - ❑ WAIVER Received r DEstfucii`ori Ifi'spzction�y �_ "�'` .��`c �� Date'ter^ � Y C n trueted Well DepthY ft COMMENTS ICJ�. ,y: •,l_. ^ ii r�: i.l i PE SC Amount �- Chec / Received Date Permit/ Invoice 4 Well 1D# Codes Info Remitted Cash By Service Request q