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OWNER NAME /�� PHONE */b � -7-4 <br /> L <br /> / <br /> OWNER ADDRESS r,'/ //G ` CrrY/STATE/ZIP <264Al-6-P/,G <br /> CONTRACTOR L-A nGtw�s i a&11 f` PHONE 3 / W_C/- -r <br /> CONTRACTOR ADDRESS /- CJ / CITY/STATE/ZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ,)<C-57 ❑C-61 ❑D-09 ❑Other NUMBER EXPIRATION DATE --O <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 Contact Name or umber <br /> TYPE OF AMK><NeW Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> -� ❑Monitoring Well(s) #of wells ❑Soil Boring(s) x ofberings ❑Geotechnical x ofboriTW <br /> ❑Out-Of--Service Well ❑Out-Of--Service Well Renewal ❑Cross-Connection Repair <br /> >CNew Pump ❑Pump Replacement ❑Pump Repair <br /> WELL CONSTRUCTION <br /> Drilling Method>1TMud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other A\ <br /> Proposed Well Depth_ft Excavation in diameter ❑Open Bottom Gravel Pack/Gravel Size in diameter /V <br /> ❑Conductor mg in diameter / Conductor Casing Depth ft <br /> -- Well Casing Diameterin Thickness/Gauge/ASTM Sched-1-30 ❑Steel 'grPlastic ❑Stainless Steel ❑Other <br /> T <br /> Grout Seal Depth /,DC7 ft ❑Neat Cement(94 lb bag/5-/D gat water) A!52and Cement /01 sack mix/7 gal water <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> E ESTAL Installed By Agbriller ❑Pump Cont <br /> r <br /> ac <br /> t <br /> ❑ Other <br /> ❑Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <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 <br /> CURRENT AND ACFIV£WITH THE CALIAORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> �IrNIMUM 24 HOUR ADVANCE NOTICE <br /> /REQUIRED FOR INSPECTIONS / <br /> SIGNED -4�- TITLEy V� /-v DATE <br /> r - -11 // `.. <br /> t ! � <br /> It <br /> 2 v — <br /> 3 <br /> G - / <br /> $n k <br /> \N <br /> L <br /> ^� DEPARTMENT U E ONLY <br /> : Fir <br /> Application Accepted By Date !l f D Area Employee ID# Y <br /> Grout Inspection B ate ❑ SPECIAL Well Permit <br /> -� Pump Inspection I .t , / Date Z-12 <br /> _ ❑ WAIVER Received <br /> Constructed Well Depth ft <br /> COMMENTS OL o L e T*OF- )(M CIk�j <br /> —C.�-G• t �'�� C.G� % ` �` - --?.[.Vii '.. .[ '?) <br />