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CONTRACTORADDRESe 45 San Clemente Drive Suile A-100 CITY/STATE/ZIP Corte Madera CA 94925 <br /> SUBCONTRACTOR N/A -_ PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATEILP <br /> LICENSE X C-57 C-61 = D-09 Other NUMBER 3 1059 9 EXPIRATION DATE 03/31/2019 <br /> GEOGRAPHICAL INFORMATION: Coordinates X 3 7.9 8 8 2 2 9 Y -121.479492 Township 02N Range 04E Section <br /> INTENDED USE _DomestiUPrivate -Irrigation/Agricullural - Industrial .Water Quality Monitoring '_.Soil Sampling/Characterization <br /> Public Water System <br /> If mlloranr from 0—, a e• y em me u a arae or one um r <br /> TYPE OF WORK X New Well . Replacement Welt Well Alteration/ Ifi lion X Other Cathodic Protection <br /> /of bori rp� <br /> _ Monitoring Wea(s) sof yells X Soil Bonng(s) 3 i+ua .Geotechnical rof t>oi: <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 X Auger Cable Tool I Push Point Other <br /> Proposed Well Depth 15 R Excavation 10 in diameter - Open Bottom Gravel PadUGravel Size in diameter <br /> . Conductor Casing N A in diarnele, / Conductor Casing Depth fl <br /> Well Casing Diameter NIA in ThicknesWGaugeJASTM Schad N/A Steel Plastic -" Stainless Steel .Other gone <br /> Grout Saal Depth 2 R X Neat Cement 194 Ib bag✓540 gal water) Sand Cement sack mix77 gal crater <br /> Bentonite(20%solids) .Other <br /> Grout Placement Method =Pumped X Free Fall Other Retardant!Accelerator(name) <br /> PEDESTAL Installed By X Driller Pump Contraclof I Other <br /> Concrete Pedestal DimensionsWidth fl Length fl Thick in X Christy Box -Stove Pipe <br /> PUMP Submersible-Turbine Other HP Pump Set R Standing Water Level fl <br /> I HEREBY CERTIFY THAT I HAVE EPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANC STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WI THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSMMMA <br /> TI U� ATI /� <br /> .26�! ANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED �� Steve McKim TITLE Vice President DATE 04/04/2017 <br /> ewe <br /> Cc <br /> Fh r <br /> I <br /> DEP R T M E N T U E NLY �������//'' <br /> Application Accepted By Data Area!7lEmployee IQs <br /> Grout Inspect Dale SPECIAL Well Permit <br /> Pump Inspection By Dale _ WAIVER Received <br /> Sod Boring In action By Dale Constructed Well Depth ft <br /> COMMENTS L� L'-- -'iE9J 1CJL{�7u'"'�/!-7LtS / –�_L�- ( {.• Z7C'S� <br /> PE SC Received Checks/ Amount Perm U <br /> PerInvoices Wall IDs <br /> Codes Into B Cash Remitted Service R uest s <br /> 11 t 47-11- y 5 11 SP-001-7154 <br /> 7 <br /> E�:) <br /> i p <br /> �tiELl rCl.MPaERutT <br />