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OWNER NAME �JIZOWIy �/�� l l t LL PHONE <br /> '1'16 y�so f <br /> OWNER ADDRESS I r L l s 1 CITY/STATE/ZIP 026-,t l�/l �'" <br /> ' CONTRACTOR ��n6r�/sS I`-� L"l'�"� PHONE 3,, V r y a7 <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP ������L^ <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS Z?CITY/STATE/ZIP <br /> LICENSE ,�C-57 13C-61 ❑D-09 11 Other NUMBERS )38—f EXPIRATION DATEy <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Owner: Water System Name ntnot Name or Phone Number <br /> TYPE OF W w New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> ❑Monitoring Well(s) #of wells ❑Soil Boring(s) a of boring'' ❑Geotechnical k of borings <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ew Pump ❑Plump Replacement ❑Plump Repair <br /> WELL CONSTRUCTION <br /> Drilling Method"*�Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth ft Excavationin diameter ❑Open Bottom _IiEGravel Pack/Gravel Size in diameter <br /> ❑Conduct0511;asing in diameter ! Conductor Casing Depth ft W <br /> Well Casing Diameter 0 in Thickness/Gauge/ASTM Sched ZJ-0 ❑Steel 01plastic ❑Stainless <br /> �Stee1 ❑Other lilnn <br /> Grout Seal Depth /�(� R E3 Neat Cement(941b bag/5-10 gal wafer) ->Mand Cement /V' 3 sack mix/7 gal water <br /> ❑Bentonite(200/.solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method->1 Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By _ZrUriller ❑Pump Contracto ❑ Other oef <br /> ❑Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑Christy Boz ❑Stove Pipe (� <br /> PUMP ✓E Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level ft + <br /> I HEREBY CERTIFY THAT 1 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 CALIPORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL Z <br /> WORKERS COMPENSATION LAWS. <br /> I�rNIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS � <br /> SIGNED '141 <br /> 1 �-4r- TITLE 0 tAj/-6• DATE <br /> Z v - <br /> 3 <br /> G - ) <br /> �N <br /> DEPARTMENT U E ONLY <br /> Application Accepted By Date ll f 0 Area Employee ID# <br /> Grout Inspection Bate �_ 13 SPECIAL Well Permit <br /> Pump Inspection B s , % Date /J�{;�7 ❑ WAIVER Received <br /> Constructed Well Depth ft <br /> COMMENTS 0(-s) (- CT' F C c=A/-) e3 C- t-J eLi <br /> n �<� '� ���r��C'1=/1f�cG�-,<YI-i"J -�'l-l�.t.�{'"�G"_''�/�'�'� �.ca %�r�= [..�i,r•.lf:.tlt=] �G-G-ZC- <-: �L'. - <br />