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.]nncn 1.r,;I.` _ tan.vl€wl at Neat 1"4 tr'CA°,;.r,= - =ErolA:,'-;__, <br /> I` tiOiN-REFL•:�D,SFLL°ER�IIi i.,A1.�Lf-2-09j s;•i_^;;u-;f:r:)S 11�YEC'IIf)' �XPIRF i E.:K�kOf%I li,STi,II StEF... <br /> jJOBADOREsS .1ax0,.f) ' Crr'•=i ZIP rf_t:i,l�?f;if <br /> ` 'i t t I� '-' 'HCl. ff- k <br /> CRusSSTRErI '� ,APS' .=VU� ,�l:' i., PARC.LSl7.E LAn'ul-[:aPrl.lc:sTlc>�; <br /> �lhl1nt^. pno'F . <br /> jIJV,TER ADDRE6S CITS'ISTATEIZIP „rr'r-��:•�,�% tl;. � CA �• -��' <br /> pF ii <br /> CONTRACTOR l Jil^1���. U11�n i ><tr Y_I�CJ PH01'E 'a I7�9 <br /> CONTRACTOR ADDRESS , 1 CIT)/STATEIZIP ( jr(�.�'� �.�� `1 Cs'3;7� 1 , <br /> i'�1ti^S Wr�_:a =�5 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATOZIP <br /> LICENSE 0 C-57 11 C-61 El D-09 ❑Other NUMBER EXPIRATION DATE <br /> GEOCRAPHICALINFORMATIOW Coordinates X Y Township Range Section �^ <br /> INTENDED USE D Domestic/Private f7 irrigationlAgricLRural ❑Industrial ❑Water Quaiity Monitoring ❑Soil SamplingrCharactenzalion <br /> D Public Water System <br /> Ir difrerrnt from Dwner: neer y,—Name C-1-1 .—or ore vm cr 7-V <br /> TYPE OF WORK 0 New We]I ❑Replacement Well 11 Well Al(erationlModitication ❑Test hole 13 Other �`-� <br /> D Monitoring Well(s) #of wells Ll Soil Soring(s) #orborings 13 Geotechnical #orborings _LL <br /> XWell Destruction D Out-Of-Service Well ❑Out-Of-Service Well Renewal <br /> D New P'um2 ❑Pump Replacement n Ptimp Repair ❑Cross-Connection Repair <br /> n WELL CONSTRUCrtON <br /> Drilling Method ❑Mud Rotary ❑Air Rotary 0 Auger 0 Cable Took ❑Push Point ❑Other <br /> Proposed Well Depth A Excavation in diameter ❑Open pattern 0 Gravel Pack 1 Gravel Size in diameter <br /> Q Conductor Casing in diameter 1 Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/GaugEfASTM Sched ❑Steel 'D Plastic D Stainless Steel 00 1 rfoe'� <br /> Grout Seal Depth ft ❑Neat Cement(941h hog/5-l0 gal wafer) ','$band Cement - W suck rnir 17 gal water <br /> Q Bentende(20/solids) ❑Manufacturer Spec°/solids % Name ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method r -Pumped D Free Fall ❑Other 11 Retardant 1 Accelerator(name) <br /> PEDESTAL Installed BY D Driller ❑Pump Contractor ❑Other <br /> D Concrete Pedestal Dimensions: Width f{ Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PLM? ❑Submersible ❑Turbine D Other HP Pump Set B 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 r <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 /> E'iUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> = f f <br /> SIGNED TITLE DATE IZn /6/— c <br /> { <br /> T 7T— <br /> ' J <br /> r <br /> f ra a <br /> i <br /> ENWHONMENTAL LilqL"! <br /> 0 D E P AR' <br /> M ENT USE ON L Y HEALTH DEPAFITMEN <br /> Application Accepted By - �/L Dale - S31s <br /> f — Area Employee I DY r 7 <br /> Crout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump{nepecti Date ❑ WAIVER Received <br /> Destruction <br /> Pump <br /> Inspeclio Date �G25 Constructed Well Depth It <br /> COMMENTS CUL <br /> PE SC Received he Amount Permit/ <br /> Codes Info By Cash Remitted Date Service Request# Invoice# / Well ED# <br /> i <br /> rf3._Z �5 � 2sc-c O <br /> WELL PIXP PERNUT <br /> RfFfa4 <br />