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INTENDED USE 0jomestic/Private D Irrigation/Agricullural ❑industrial ❑Water Quality Monitoring ❑Soii Sampling/Charactcriximan <br /> ❑ ublic Water Syystem <br /> I(rlfrerent tram Own.r. .ter "1r a onracr ameor one um er <br /> TYPE OF\YORK New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole D Other <br /> ❑Monitoring Well(s) #ofwells ❑Soil Borings) Rofb-mings D Geotechnical >f of borings <br /> _ ❑Well Destruction ❑Out-Of-service Well ❑Out-Of-Service Well Renewal <br /> D New?ump D Pump Replacement ❑Pump Repair ❑Cross-Connection Repair <br /> WELL CONSTRUCTION <br /> Drilling MethodJ�Mud Rotary ❑Air Rotary 11 Auger [I Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth _ R Excavation /Z -in diameler ❑Open Bottom �'Ciravel Pack!Gravel Size in diameter <br /> D Conductor Casing in diameter I Conductor Casing Depth R <br /> Well Casing Diameter <br /> �''�in ThicknesslGauge/ASTM Sched 2 ❑Steel 'Plastic ❑Seamless Steel Q Other v <br /> Grout Seal Depth�ft Q Neat Cement(94 1h hug/5-10 gerl wuterJ ❑ and Cement .tuck mix!7 gal water �( <br /> l�aentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on Fele ❑Specs Submitted ' <br /> Grout Placement Method umped ❑Free Fall D Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By Q Driller Xfump Contractor Q Other <br /> ❑Concrete Pedestal Dimensions: Width_ R Length_R Thick in D Chrism Box D Stove Pipe <br /> !T} <br /> PUMP D Submersible D Turbine ❑Other HP Pump Set R Standing Water Level 17 <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 i. <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> InAA c <br /> SIGNED P YYf_!l`L^!'� TITLE QVl DATE <br /> OF <br /> Q <br /> 0' S D <br /> T 0 <br /> DEPARTMENT USE ONLY 1/1 <br /> Application Accepted By -c Dale -S y Li"' Area Cmployce ID# <br /> Grout lnspeciion By Dale -571 <br /> ElSPECIAL Well Permit <br /> Pump tnspection By Date ❑ WAIVER Received <br /> Destruction Inspection By Date Constructed Well Depth/ ft <br /> COMMENTS ,�L�Fw L.r%G� ,,?EC.cs2r� .St-;�;`l.C- .5�-CTT_.^-f fi-�.,,.'_.=,.4.•1'� t rv�>7iLr_.F__!S I LE' 2G�cS <br /> PE SC Received hec Amount ate Permit! Invoice H Well rD# <br /> Codes Info ash emitted Service Re uest# <br /> EHD 47.02-W,� WELL PUMP PERMIT <br /> WN04 <br />