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r rt VF WORK 0 Replacement Well "eme�� they�- I <br /> �---._ �Bi;New Well /` [i 0 ❑ Geotechnica <br /> ❑ Monitoring Wells Alteratio ion Repair <br /> ❑ Well ation orings <br /> g O #of wells ❑ Soil Boring(.)n/iodlhc of b Cross-Connect _ <br /> ❑ Out-Of-Service Well Well Cerin <br /> ew Pum ❑ Out Of se". �wal p Raise <br /> yy ��T _ ❑ Pum Re lacement ❑ Pum NiceWellR 0DrllliO Re air Other❑ Gravel Pa�/Gravel Size <br /> Proposed Well Depth , `� Air Rotary ❑ Auger ❑ Cable To ush Point <br /> ft Excavation /�� of rl P Oen BOtt°m " ft pthe <br /> �-- in diameter i p ❑ <br /> ❑ Conductor Casing p Stainless Steel sock. <br /> Well Casingt in diameter / Conductor Casing Depth `D P <br /> Diameter lastic <br /> Grout Seal Depth �,in Thickness/Gauge/ASTM Sched��` i Steel '❑ Sand Cement <br /> --�_ft fl Neat Cement(941b bag/5-1p gal Water) <br /> 0 Bentonite(20%solids) I Other lerator(name) <br /> Grout Placement Method*'pumped ❑ Free Fall 11Other I Retardant/Acce <br /> ❑ S <br /> PED s AL Int <br /> salled B in ❑ Christy Box <br /> Y - Driller ❑ Pump Contractor.. ❑ Other R Thick <br /> 0 Concrete Pedestal❑Dimensions:Width ft Water Levef <br /> Length ft Standing DA <br /> PUMP +(Submersible❑ Turbine Set_�� CCQ <br /> ❑ Other HP.f Pump BE p0 E I LIA <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION ANO yI/QRK W�L�Lw .„-.T IN COMP <br /> JOAQUIN COUNTY O?Dk',A`JCES, T THAT THE THAT I AiV7 <br /> CURRENT AND ACTIVE WITH THESCAL FORK A C^NO RULES AN-ONTRACTORS STA E LICENSE BOARD AND 953_76 <br /> WORKERS COMPENSATION LAWS. PLEASE CALL (209, <br /> MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS ' DATE <br /> SIGNED ,"- TiriE <br /> 1 <br /> t ) 1 <br /> r p <br /> �c <br /> 1 I � <br /> trj1 <br /> 1 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Area <br /> Grout Inspection By Employee I <br /> Date 0 SPECIAL Well Permit <br /> Pump Inspection By Date <br /> Soil Boring Inspection By El WAIVER Received <br /> COMMENTS Date Constructed Well Depth <br /> PE SC Received Check#/ <br /> Codes Info B Cash Amount Permit/ <br /> Remitted Date Service Re uest# Invoice# <br /> i <br /> i 4 <br /> i <br /> EHD 43-06 9/01116 <br />