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40ew Well the _ <br /> ❑ Replacement We11O r <br /> ❑ Well Alter ❑ Geotechnica <br /> ❑ Monitoring Wells) #of wells ❑ Soil Bori 9(s° �fication ar arin98 air <br /> ❑ Out-Of-Service Well <br /> nod Cross-Connection Rep <br /> ew,Pum ❑ Out-Of-Seryi�Welwval a Raise Well Casin <br /> WELL ❑ Pum Re lacement ❑ Pum <br /> S Re air <br /> DrllllJIM 0 poen ❑ Other vel P Gravel Size <br /> �O Air Rotary. ❑ Auger ❑ Cable Tool push t om Gra acW <br /> Proposed Well Depth �"?r; sh <br /> ft Excavation %_ly I i Open So ft ❑ other <br /> ❑ Conductor Casing �— �n d�ar%ter Steel SeCk <br /> in diameter / Conductor Casing Depth D plastic ❑ Stainless rrl <br /> Well Casing Diameter in Thickness/Gau a/ASTM Sched 11 Steel Cement <br /> Grout Seal �,: r� g C Sand Cem <br /> Depth ❑ Neat Cement(94 Ib ba i�l <br /> ❑ Bentonite(20%solids) Cl Other 9 1p gal waterl name) <br /> Grout PI Accelerator( <br /> Placement Method$'pumped ❑ Free Fall 11 Other Retardant I ❑ StO <br /> PEDES AL in ❑ Christy BOX <br /> ---L Installed By Drill <br /> ❑ Concrete Pedestal❑Di en ionsF1 Pump CWtdractor ft Length ft Thick��ft Standing Water Level <br /> PUMPC <br /> •f�Submersible❑ Turbine Pump Set ON E iN .7101 <br /> 0�, <br /> I HEREBY CERTIFY THAT I HAVE p [] Other HPI WILL BE�„D�-r> = COMPLIfy <br /> PREPARED THIS APPLICATION AND THAT THE tN0 D AND THAT i AM IN <br /> "'C'U1N COUNTY 071DIpIANCES, STATE LAWS; ANO RULES AN- ND LICENSE <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS S7A� _ BOAR _ PLEASE CALL (2 DATE 953-76 <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS DATE <br /> SIGNED ' TITLE <br /> Ij <br /> 1 <br /> IQ <br /> t O <br /> 1 <br /> C' rjf' 1 <br /> \' DEPARTMENT USE ONLY <br /> Application Accepted By Date Area <br /> Grout Inspection By employee I <br /> Pump Inspection By <br /> Date ❑ SPECIAL Well Permit Soil Boring Inspection By Date <br /> ❑ WAIVER Received <br /> COMMENTS Date Constructed Well Depth <br /> PE SC Received Check#/ <br /> Codes Info g Amount <br /> Cash RemittedDate Permit/ <br /> Service Re uest# Invoice# <br /> EHD 43.06 e/01/16 <br />