Laserfiche WebLink
� Vt�1�4n..n..c ► •..v• <br /> t OWNERADDRESS 16930 E. Coknstock Rd. CITY/STATE/ZIP Linden, Ca 95236 <br /> CONTRACTOR Purviarlce Drillers, Inc. PHONE209-8a7-3554 G <br /> CONTRACTOR ADDRESS P.0• BOX 64 CITY/STATE/ZIP Linden, CA 95236 -Ij <br /> SUBCONTRACTOR n/a PHONE <br /> 1 SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE IXC-57 ❑C-61. ❑D-09 ❑Other NUMBER 377923 EXPIRATION DATE?/3 0/0 3 11 t' <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE IXDomestic/Private ❑,drrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Owner-. Water System Name Contact Narne or Phone Number <br /> TYPE OF WORK 1XNew Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole " ❑Other <br /> ❑Monitoring Well(s) number of wells ❑Soil Boring(s) number ofborinbs ❑Geotechnical number of borings <br /> ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal <br /> IXNew Pump ❑Pum°Replacement ❑Pump Pe it ❑Cross-Connection Repair <br /> R WELL CONSTRUCTION <br /> Drilling Method IXMud Rotary ❑Air Rotary ❑Auger ❑Cable Tool O Push Point ❑Other <br /> Proposed Well Depth 30 0 H Excavation 12 in diameter X Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter 6�t$ Thickness/Gauge/ASTM Schedof Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth 200 tt ❑Neat Cement(94 th bug/540gal water) IN Sand Cement 10.5 suck rnLr/7 gat water <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method IN Pumped ❑free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑Other - <br /> ❑Concrete Pedestal Dimensions: Width ft Length fl Thick in ❑Christy Box 13 Stove Pipe <br /> PUMP IA Submersible 0-Turbine 13 Other HP 3 Pump Set 252 11 Standing Water Level ft <br /> WELL DESTRUCTION 13 Open Bottom ❑Gravel Pack ❑Uncased ❑Other <br /> Well Diameter in Total Depth ft Depth-to-Water Water ft ❑Casing to be Perforated from ft to it <br /> Sealing Material 13 Neat Cement(94 lb bag/S-10gu1 water) ❑Sand Cement suck II/7 gal water ❑Bentonite Pellets <br /> r' ❑Bentonite(20%solids) ❑Manufacturer Spec%solids '-- <br /> % Name ❑Specs on Filo O Specs Submitted <br /> Placement Method ❑Pumped ❑Free Fall ❑Other — <br /> Complete with Mushroom Capt, ft below grade ❑Complete to Existing Surface Pad <br /> 1 HEREBY CERTIFY THAT IiHAVE 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 I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSAT S. <br /> _`NI UM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> i <br /> 4 stcNe TITLE Corporate Secretary DATE 11 /13/02 - ' <br /> F <br /> • I <br /> r <br /> 11 <br /> I1 <br /> r <br /> N.n <br /> w' e <br /> ' J <br /> S1 T4 t1 <br /> 5. <br /> itH <br /> ' DEPART ENT USE LV <br /> Application Accepted By Date p <br /> D — Area ZI Employee ID# Y(J <br /> Grout Inspection By Date 2 - ?s ESPECIAL Well'FFt if• - <br /> Pump Inspection By Date ❑ WAIVER Received � <br /> Destruction Inspection By Date �onstru ed Well Depth ft <br /> COMMEN 1e t7 ' <br /> br/ 3 A)- <br /> PE SC Amount C Received <br /> Codes I Info Remitted ..A <br /> ash By^ Date Service Re uest# Invoice# Well ID# <br />