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14' WELL / PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTAPdARTMENT 304E WEBbPWVE 3Y0 FL- STOCKTON CA 95202 - (209)468-3420 _. __..-____._ . _. .. n.........rAI.1. 121119195-3-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED JOB ADDRESS 600 Hewitt Rd. CITY/ZIP Linden //�� ,/ CROSSSTREET Copperopolis Rd. APN ff -Ow-Q3 P`ARCELSIZE q- :JC OwNERNAME Collett r s Board & Care Home PHONE �7T Z2-4 OWNER ADDRESS 1625 W. Whitmore CITY/STATE/ZIP Modesto CA 95358 CONTRACTOR Purviance Drillers Inc. PHONE 209-887-3554 CONTRACTOR ADDRESS P.O. Box 64 CITY/STATFJZIP Linden, Ca 95236 SUBCONTRACTOR SUBCONTRACTORADDRESS LICENSE M C-57 ❑ D-09 ❑ Other CITY/STATEJZIP NUMBER 37792 PHONE 7/31/05 rrnru.mnrsr.INVAUMATION: Coordinates X Y Township_ Range_ Section INTENDED USE M Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization ❑ Public Water System If diffiment from neo water Sysurm Nam Cannot Name or Phone Number TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification U Test Hole U Other ❑ Monitoring Well(s) number ofwcas ❑ Soil Boring(s) number ofborinyn ❑ Geotechnical ❑ Well Destruction ❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal U number of borings WELL CONSTRUCTION Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other Proposed Well Depth 11 Excavation in diameter ❑ Open Bottom ❑ Gravel Pack / Gravel Sin in diameter ❑ Conductor Casing in diameter / Conductor Casing Depth Well Casing Diameter in Thickness/Gauge/ASTM Schad ❑ Steel Grout Sed Depth ft ❑ Neat Cement (94 lb bag / 5-10 gal wafer) ❑ Bentonite (200/ solids) ❑ Manufacturer Spec %solids _ °/ Name Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retar ❑ Plastic ❑ Stainless Steel ❑ Other ❑ Sand Cement .rack mix / 7 gal water ❑ Specs on File ❑ Specs Submitted PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other ❑ Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe PUMP (ISubmersible bii��Ot y � � t- n, lt. t njDyg�f�evel ft WELL DESTRUCTION ❑ pen Bottom LI Olavel P ek ❑ U cased ❑Other Well Diameter in Total Depth It Depth to Water ft ❑ Casing to be Perforated from ft to ft Sealing Material ❑ Neat Cement (94 16 bog/5-10 gal water) ❑ Sand Cement sack mix / 7 gal water ❑ Bentonite Pellets ❑ Bentonite (20% solids) ❑ Manufacturer Spec % solids —% Name ❑ Specs on File ❑ Specs Submitted Placement Method ❑ Pumped ❑ Free Fail ❑ Other ❑ Complete with Mushroom Cap it below grade ❑ Complete to Existing Surface Pad 1 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 1 AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. �A4flVlMU 24 1 R ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 Corporate Secretary DATE8/10/04 w a n O O Q Q