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I.ROSSSTREET 1 " 1 fC.II IL.yv✓`7 1'c" APN Ui:)/4VV(j/ a <br /> 'T� PARCEL SIZE- •• LAND USE APPLICATION# 7 m <br /> OWNER NAME �Gl' +'71 It-- <br /> C R SS cCj�Gt.f� L-�(/rpt PHONE 20,17 <br /> OWNER ADDRESS U! '7r � /�/� <br /> I �eaiTp k-!�q CITY/STATE/ZIPF�J /,,/ 1� 11f� <br /> CONTRACTOR _ Ne U• 7 <br /> ff r� CS�Y/ /�� (�CI ?_��J PHONEy-) Lr / /n! <br /> CONTRACTOR ADDRESS r�C1 ll7d(/$ -�/(/Q CITY/STATE/ZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS �` CITY/STTA,�TEEIZIP 7 <br /> LICENSE C-57 r NUMBER-" 604 EXPIRATION DATE !/ <br /> GEOGRAPHICAL INFORMATIOI(�j,C a Y Township Range Section <br /> INTENDED USE Domestic/PtiftpgOt �gric dustrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water Sy4G" <br /> If different fromOwner 0 a er y Contact Name or Phone Number <br /> TYPE OF WORK New Well Replai4& 0IIA t dification , Other <br /> 01 ? S of borings k of born s <br /> Monitoring Well(s) �Irs S 'ng 9 Geotechnical e <br /> Out-Of-Service Well ervice Well Renewal Cross-Connection Repair <br /> New Pump Pump Re lacement -"FU pair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method X Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Well Depth 1S Excavation _ in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter ! Conductor Casing Depth R <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched Steel . Plastic Stainless Steel Other <br /> Grout Seal Depth ft - Neat Cement f(�41b bag/,-IOflg /�ater) Sand Cement sack mixr7 gal water <br /> Bentonite(20%solids) �Other C �.�'� I ^ i <br /> Grout Placement Method Pumped Free Fall - Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller I Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width ft Length ft Thick in Christy Box Stove Pipe <br /> PUMP Submersible Turbine I Other HP Pump Set It Standing Water Level It <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 ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIM M 24 HOUR ADVANCE NOTICEREQUIREDFOR INSPECTIONS Xn <br /> SIGNED TITLE / NI/�G�� DATE (J ,`5 ^1 <br /> jj� <br /> Y <br /> 11� - <br /> r� { <br /> naEN T <br /> rvn <br /> ti` n <br /> 9 lull".1 <br /> 99 /L�sjO�r� <br /> ,, �u.• ra: • <br /> T i . i f I i LLLJ I I I I i. I I I I - <br /> f,DE ARTMENT USE ONLY <br /> Application Accepted B Date Area Employee ID#C�k - <br /> Grout Inspection By <br /> Date SPECIAL Well Permit Ali <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring I spection By �,, Date Constructed Well Depth It <br /> COMMENTS Boring <br /> �//s�vni�M96Y; 'r< ��A 0,Z,/2 . All, �S{dli(L AJ <br /> , // IZ <br /> , _r . �, � ---- & -- ---------- -------- - -- -- <br />