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' OWNER NAME—/Jj O YSOL IO�AST" <br /> rTSr PHONE 606'—-4-0 <br /> �I� G+ l <br /> OWNERADDRESS <br /> //2CI'L N ALo«G �Y CrrWSTATFJZIP , •] 7oC-16 � <br /> � �>� Goons �n,tli�. ' 33 y- �!?�-s' <br /> PHONE <br /> ' CONTRACTOR / ? <br /> CONTRACTOR ADDRESS <br /> BD`F, 1-7� CITT/STATE2IP �r S� <br /> PHONE . <br /> SUBCONTRACTOR <br /> ' SUBCONTRACTOR ADDRESS CINISTAT`ErLIP <br /> LICENSE )eC-57 C C-61 C D•09 C Other NUMBERS 773tr' E%PIRA'nON DATE <br /> ' GEOGRAPHICAL INIroRMATION: Coordinates X Y Township— Range_ Section <br /> INTENDED USE fKloomestldprivata D ImgationlAgricultural OIndusWai L;Water Quality Monitoring DSoil SamplinglChamcterization <br /> C Public Water System ame or In <br /> Ifdif mn1frcmwn <br /> Oer er ys m erre \ <br /> TYPE OF WORN �wNew Well C Replacement Well Well AlteratiordModlflcation aw mer pof borirge <br /> C Monitoring Wells) #of wells C Soil Bcring(s) C Geoted[nicel <br /> C Out-Of Service Well U Out-OfSeivice Well Renewal D Cross-Connection Repair <br /> New Pum -1 Pump Replacement -i Pumn Re Ir 7 Raise Well Castn <br /> WELL CONSTRUCTION <br /> Grilling Method-AVud.7 <br /> Rotaryyc C Air Rotary C Auger J Cable Tool D Push Point 7 Olher <br /> ' <br /> Dr <br /> Well Depth �=R Excavation �Z. in diameter C Open Bottom Gravel PariclGravel Stze in dlameter <br /> Conductor sing in diameter I Conductor Casing Depth ft <br /> C <br /> Well Casing Diameter6in Thickness/Gauge/ASTM Schedl as D Steel XPlastic U Stainleee,555�sss Steel D Other <br /> Grout Seal Depth 0 R G Neat Cement(94 Ib bag/5.10 gal water) A'Sand Cement A)i 3 sack mixR gal water <br /> ' C Bentonite(20%solids) ❑ Other <br /> Grout Placement Meth0d)d Pumped C Free Fall D Other D Retardant I Accelerator(name) <br /> PEDESTAL Installed By ><Dell 7 Pump Contractor C Other <br /> D Concrete Petlesfal Dimensions:Width ft Lengtll ftThick in ❑Christy Box D Stove Pipe <br /> PUMP SubmersibleC Turbine C Other HP Pump Set ft Standing Water Level ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I 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 COMPENSATION LAWS. <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS f G <br /> ' (jWl�blt_ ✓ �o l <br /> SIGNEO�� TITLE DATE��r-A� <br /> T _ <br /> 1 <br /> C <br /> ' a <br /> ' J A <br /> E <br /> ENT USE ONLY -s/ L <br /> - paty Area Employee ID# <br /> Application Accepted O <br /> Grout Inspection Date SPECIAL Well Permit <br /> Pump Inspecti Date �ryt-2— VER Received <br /> Soil Boring Inspection By Date Constructed Well epth R <br /> COMMENTS <br /> e..—W ..__ <br />