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CROSS STREE IV,/aD�T �il!i.I APN _PARCEL SIZE LAND USE APPLICATION# m <br /> ea cr" N <br /> OWNER NAME 4S0z;,-­4-14 &! F M A—19,177 PHONE <br /> �ii-E 1r.S <br /> OWNER ADDRESS + �nj �^ CITYISTATE/ZIP J /(' <br /> CONTRACTOR x ('r/�4 ,[.'ter ./1(�C PHONE-2.0 --� 4<6 1,J �T J <br /> • CONTRACTOR ADDRESS_�0 ,L1 r'a-\ In�_ 1O0TY/STATE/ZIP,� C, 4� �d Of T-� <br /> SUBCONTRACTOR _P— `. �`. i PHONE CO _ 7 7 <br /> ' / <br /> SUBCONTRACTOR ADORES C t lQr�� '1,n, CbITY/STATEZIP �C-�'�' �J S - <br /> Js=�.w4—L '1f� Q <br /> LICENSE �C-57 C 6�O r 09 o Othert NUMBER 3 6 7' 7 /U <br /> EXPIRATION DATE � / <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Ksoil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells 01Soii Boring(s) #of borings Geotechnical i 4#of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary (Auger Cable Tool Push Point Other_�p ya'1.L� <br /> Proposed Well Depth 1n—19­0 ft Excavation c�—� in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other 1 <br /> Grout Seal Depth It gJeat Cement(94/b bag/S10 gal water) Sand Cement sack mix/7 gal water ^r 1 <br /> Bentonite(20%solids) Other I F &d D 6 u) S(O t C Cc&7 A)&r C O k <br /> Grout Placement Method Pumped Free Fall Other rc E Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width It Length It Thick in Christy Box Stove Pipe ('I <br /> A <br /> PUMP Submersible Turbine 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 41. <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINONUM24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED \� '�'^�- TITLEC�%VW-a-y- DATE <br /> V <br /> MIFIV <br /> EMy <br /> SO Q IN O <br /> ,. 'r <br /> EPARTM.ENT USE ONLY -- - I <br /> Application Accepted By Date Area Employee ID# LS-IF q / G <br /> Grout Inspection By Date SPECIAL Well Permit / <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring inspection By i �r� ti/ Date Constructed Well Depth ft <br /> COMMENTS ����L DC7 �G2 � f x l �� !«flit/✓'��iJ44 u,��u if . -1:11r- <br /> A3 &--2 r,/ GXe4,e - lsri'"T1/5 lyJi7,V <br /> PE Sc Received Amount Date Permly Invoice# Well ID# <br /> Codes Info By Cash Remitted Service Request# <br />