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N � <br /> (� C <br /> lD <br /> 00 <br /> O _ IPwP03ed Well �'Pt""'— tor Casing_ =m 0iamerer r �,VnuV•_r�=Jy :.Pta'*( v <br /> car d„c Steel tin <br /> 0 ,n Thickness/CaugerASTM Sched_-- <br /> CL <br /> ,.gand m <br /> �. Diameter_ - a <br /> I Well Casing R Neat Cement(94 lb baq'S 10 gal wafer) <br /> r I Grout Seal Depth - -'- <br /> Eenfonile121)°-sohdsl Other <br /> � — tardant I Aa <br /> o <br /> IG-roul Placement Method <br /> Pumped Free Fall Other <br /> oc <br /> V <br /> Q) Installed By Driller Pump Contractor ter o R Thick_ <br /> PE_DEITAL <br /> Concrete Pedestal Dimensions:Width ft Length <br /> PUMP Submersible Turbine Other <br /> Hp o mp Sel_ <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND TH HE WOE <br /> OAninN rp'J.7Y ngn!NANCEc cTATS LAWS, ANL' SULES AND REGI: <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRAC70RS STATE <br /> `, WORKERS COMPENSATION LAWS. <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> Au rJ Tau <br /> r SIGIAM <br /> rz <br /> L n <br /> mI <br /> n <br /> Q: <br /> 6� <br /> J 1 J <br /> c Qr 1 <br /> Z <br /> r <br /> z <br /> na � ! l 1 <br /> _ J _ l <br /> SL <br /> w <br /> J <br /> i IL <br /> Ilu <br /> C Q <br /> 2 <br /> DEPARTMENT USE E QNLY -C <br /> 0 m APPlication Accepted By <br /> r,/ 1 r0 <br /> 2 r - Date a� <br /> oGrout Inspection By = <br /> Date ro <br /> Pump Inspection By c <br /> N Date a, <br /> Soil Bonng Inspection By E <br /> COMMENTS <br /> Date 0 <br /> 00 <br /> w <br /> Ln � PE SC ry <br /> `D 3 COs Into Recettred Check/_/ Amount ro <br /> C `'eetfi Remittedt Dab <br /> cuc <br /> ro <br /> Qj <br /> ru <br /> �n d 7. D <br />