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NVELL PIL NIP -PERMIT <br /> yN J(_uu. ICOT'T! c,:,IRt. �'-r I.He n LTsi D-.,,R I'I E,-! <br /> I NO'` RF,`UNDABLsL-�1P£RM1ll CALL(209)9j3-709'FoR 9'vyFEC.!O"' VIRES ! [AR[RO'sl DATE ISSUED <br /> F iJOIIADDRRS� /<74 : •-� 1� •� r CITs:?Ir �.'f )'F')'Y' _ <br /> `CROSS Sr RE ET ��.,�-�:(�1r f 7l - s PN L-k i)f sE APPt.ic.rio, j <br /> I0\i7•IER NAME 1 PHOIE I f <br /> i <br /> OWN'E0..AODRESS CITVNTATE'ZIP I, <br /> CONTRACTOR �L' �V�;l • j�W/LI � lrl.,� PHONE-?M <br /> CONTRACTOR ADDRESS 7 CITYISTATEIZ.IP - <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATEIZIP <br /> LICENSE D C-57 ❑C-61 ❑D-a9 ❑Other NUMBER RTPIRATION DATE <br /> G EOGRAPH ICAL INFORMATION: Coordinates X Y Township Range Section <br /> �IiNTENDEDSE omesticlPrivate ❑Trrigation/AgricullLrai 11 Industrial 0 Water Quali ly Monitoring ❑Sail Samplirg)Characicrization —1 <br /> ❑Pubiic Water System <br /> Ifdiffmrt Rom Dwne1. ager yamm amr ontarl,amr ar oneuFner <br /> TYPE OF WORK ;ji�CW Well ❑Replacement Well 71 Well Alteration/Modification ❑Test Hole ❑Other <br /> N ofhorinbs p of 6a6nys ✓� <br /> iI <br /> ❑Monitoring WeI I(s) #of wells ❑Soil Boring(s) ❑Geotechnical ; <br /> []Well Destruction 0 OuI-Of-Service Well ❑Oul-O f-Service Well Renewal <br /> fPump ❑Pump Replacement ❑?ump Repair ❑Cross-Connection Repair j <br /> WELL CONSTRUCTION / <br /> I Drilling Method ❑Mud R ary _ 'I Air Rotary ❑Auger /Cable Tool C Push Point ❑Other <br /> V <br /> Proposed Well Depth �' R Excavation in diameter '�4pen Bottom ❑Gravel Pack!Gravel Size in diameter <br /> 00 onductor Ca'ng _..�in diameter 1 Conductor Casing Depth fl <br /> Well Casing Diameter in Thickno slGauge/ASTM 5ched _ eel ❑Plastic 11 stainless Steel Q Other r• <br /> Grout Seal Depth B 13 Neat Cement(94 ib bag/5-70 gal wider) and Cement .ruck mit 17 gal water <br /> ❑Bento Vie(20%solids) ❑Manufacturer Spec%solids_% Name ❑Specs on Pile ❑Specs Submitted <br /> Grout Placement Method oEAIE roped ❑Free Fall ❑Other ❑Retardant I Accelerator(name) <br /> PEDESTAL Installed By -4�rller '291rrmp Cceit a or ❑Other <br /> ncrete Pedestal Dimensions! Width tt Length fl Thick in ❑Christy Box ❑Stove Pipe <br /> e <br /> PUMP RFUrrt Bible ❑Turbine ❑Other Standing Water Leve! s I <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. 1 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 /> NIJMMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED ._ -s-- _"_.� _ IT4E C.-1 DATE <br /> r <br /> I` <br /> ' N <br /> pit NP - <br /> " sy 1R {sP <br /> L <br /> E AR ENT US - O LY �j <br /> Application Accepted By - Area 2- Employee ID# <br /> Grout Inspection �-G - Date /�S�n,`- 13 SPECIAL Well Permit / t� <br /> Pump Inspection By Dale ❑ WAIVER Received <br /> Destruuctutrdnnsspection <br /> CO MENTS-� < lK <br /> PE SC Received Check#1 Amount Dafe Permit! Invoice# Well IDN <br /> I Codes Info B Remitted Service Request f! <br /> $ C� {���r �o ZEN i-t U Q <br /> ©S-3 NL-Cr uk'l, o© -V- <br /> WELL <br /> WELL PUMP PERMIT <br /> EHD 0-02.006 <br /> ernraa <br />