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' OWNER NAME 11^12144V_3rk:5A W�OZ <br /> ' PHONE _35/1^�_®L yt <br /> OWNER ADDRESS CITY/STATE/ZIP 41/-Z-Tv 4 .%5_Z; <br /> M <br /> PHONE <br /> d �N <br /> CONTRACTOR <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP 59E/X/ <br /> SUBCONTRACTOR /�% j PHONE <br /> tSUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE 57 fi l Cl D-09 ❑Other NUMBER EXPIRATION DATE fTt <br /> ' GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section \11 <br /> INTENDED USE omestic/Private ❑Irrigation/Agricultural E3 Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System Contact Name or one Number <br /> ' If different from Owner: Water System Name _ <br /> TYPE OF WORK ew Well ❑Replacement Well ❑Well Alteration/Modification ❑Other q of borings <br /> a of borings ❑Geotechnical <br /> [3 Monitoring Well(s) #of wells 11 Soil Borings) <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair ISN <br /> ' joew Pum ❑Pump Replacement ❑Pump Repair <br /> WELL CONSTRUCTION <br /> Drilling MethodMud Rotary ❑Air Rotary ❑Auger [3Cable Tool ElPush Point ❑Other <br /> ' Proposed Well fWDepth '34M ft Excavation z in diameter ❑Open Bottom ravel Pack/Gravel Size in diameter <br /> ❑Conductor in- <br /> Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diamet Thickness/Gauge/ASTM Sched G4 1400 ❑Steel AUPlastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth_ ft ❑Neat Cement(94 lb bag/5-10 gal water) ❑Sand Cement sack mix/7 gal water <br /> ' ❑Bentonite(200/.solids) ❑Manufacturer Spix%solids % Name ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method ktfumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> ' PEDESTAL Installed By ❑Driller ❑Pump Contractor Other <br /> ❑Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP ubmersible ❑Turbine ❑Other - Pump Set ft Standing Water Level <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 /> MUM 24 iJOUR ADVANCE NOTICE REgUIRED FOR INSPECTIONS <br /> 1 - °� - <br /> SIGNED TITLE DATE <br /> C. <br /> �- - Z <br /> Q � <br /> ' 7- <br /> 7 —Ld Nil <br /> _ .l <br /> 101 <br /> i ; <br /> _ a <br /> r^ 6 <br /> 114 <br /> r <br /> 2. <br /> ' ` ( T l.. Z ' i 7. tr C <br /> l <br /> E`P RTMENT SE NLY ?L-�3 n <br /> :,421_ fir. <br /> Application Accepted Date Area mplo'yee ID ' <br /> ' ' Date 2 A� ❑ SPECIAL Well Permit <br /> Grout Inspection By . �t�= <br /> Pump Inspection By Date ❑ WAIVER Received <br /> ' Constructed Well Depth ft <br /> COMMENTS LC3!!G` �i 4(4 1 jJt:0 <br /> �CZIC�' C7E Z'rcz-G Ga` t/ j C<i G G/ ?[ L< L•telk ms' <br />