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'OWNER ADDRESS P. . 0. Box 317.50 CITYISTATE/ZIP Stockton, Ca 95213 CONTRACTOR Purviance Drillers, Inc. PHONE209-887-3554 I CONTRACTOR ADDRESS P•O•BOX 64 CITY/STATE/ZIP Linden, CA 95236 t • i SUBCONTRACTOR n/a PIIONE SUBCONTRACTOR ADDRESS • g CITY/STATE/ZIP LICENSE C-57 ❑C-61 ❑D-09 ❑Other NUMBER 377923 EXPIRATION DATE 7/03 \A i GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE 5j Domestic/Private 0 Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring O Soil Sampling/Characterization D Public Water System . If different from Owner: Water System Name omact oma or one um er TYPE OF WORK N New Well 0 Replacement Well 0 Well Alteration/Modification ❑Test Hole ❑Other l ❑Monitoring Well(s) numberofwells 13 Soil Boring(s) number of borings C3 Geotechnical number of borings O Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal lift New Pump ❑Pump Replacement O Pump Re air ❑Cross-Connection Repair WELL CONSTRUCTION i Drilling Method Ca Mud Rotary ❑Air Rotary ❑Augcr O Cable Tool ❑Push Point ❑Other Proposed Well Depth 400 ft Excavation 17 in diameter M Open Bottom ❑Gravel Pack/Gravel Size in diameter t ❑Conductor Casing' in diameter / Conductor Casing Depth ft Well Casing Diameter 8.612 ahickness Gauge/ASTM Sched .156 N Steel ❑Plastic ❑Stainless Steel ❑Other Grout Seal Depth 2 0 0 - ti 0 Neat Cement(94 lb hog/5-10 gat water) Sand Cement 10.5 sack mix J 7 gal water t]Bentonite(20%solids) ❑Manufacturer Spec%solids % Name O Specs on File ❑Specs Submitted Grout Placement Method 11 Pumped ❑Free Fall ❑Other O Retardant/Accelerator(name) j PEDESTAL Installed By ❑Driller O Pump Contractor O Other t ❑Concrete Pedestal Dimensions: Width It Length it Thick in 0 Christy Box O Stove Pipe PUMP I1 Submersible " ❑Turbine ❑Other HP___5_ Pump Set 10 5 ft Standing Water Level ti WELL DESTRUCTION q5pen Bottom ❑Gravel Pack ❑Uncased ❑Other Well Diameter in Total Depth ft Depth to Water H ❑Casing to be Perforated from ft to tt Sealing Material 0 Neat Cement(94 lb bug/5-10 gal water) ❑Sand Cement sack rnic/7 gal water 0 Bentonite Pellets I' ❑Bentonite(20%solids) 0 Manufacturer Spec%solids % Name 0 Specs on File O Specs Submitted j Placement Method ❑Pumped• 13 Free Fall ❑Other 1t 0 Complete with Mushroom Cap ft below grade 0 Complete to Existing Surface Pad j HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN ; JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND.REGULATIONS. I 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- WORKERS COMPENSATION 1 M 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS SIGNED TITLE Corporate Secretary DATE1 0/1 0/02 El dil t t in A. i DEPARTMENT USEONLY t — ,,ApplicationAOSepted�y +..._ Date Area Employee ID# ! • v t - f Grout Inspection By Date `' "17 SPECIAL a Mermt r Pump Inspection By Date ❑ WAIVER Received p'�^^*—'De§true'tion 7fispEcti$o B " -" " �` - date Constructed Well Depth ft i COMMENTS y PE SC Amount +•� Chec / Received Permit/ j Codes Info Remitted Cash By Date Service Request # Invoice# Well 1D#