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INTENDED USE $7 DomesticlPrivate ❑Irrigation/Agricullural ❑Industrial ❑Water Quality Monitoring 0 Soil Sampiing/Characterizatian <br /> ❑Public Water System <br /> Ifdiff rent 11—Owner -r ysmm ame Dorso acne w ane um er <br /> TYPE OF WORK _❑New Wetl ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other <br /> ©Monitonng Well(s) #of wells ❑Soil Boring(s), x of borings 0 Geotechnical n oFb,rinp <br /> 0 Well Destruction ❑Out-Of service Wel{ ❑Out-Of-Service Well Renewal <br /> $XNew Pump ❑Pump Replacement ❑Purrp Repair ❑Cross-Connection Repair <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger C Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth ft Excavation in diameter ❑Open Bottom ❑Gravel Pack 1 Gravel Size in diameter <br /> ❑Conductor Casing in diameter f Conductor Casing Depth <br /> Well Casing Diameter_in Thickness/GaugelASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth R Q Neat Cement(94!h hug/S-!0 gal water) Q Said Cement sack mix 17 gal water fel <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids_% Name 0 Specs on Filc ❑Specs Submitted <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑Other D Retardant/Accelerator(name) <br /> PEDESTAL Installed By 0 Driller ❑Pump Contractor ❑Other 4,` <br /> ❑Concrete Pedestal Dimensions: Width_R Length__-___`tl Thick in Cl Christy Box ❑Stove Pipe <br /> PUMP E Submersible ❑Turbine ❑Other HP 2 Pump Set 168 A Standing Water Level 121 fl � <br /> 1 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, 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS 7< <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WIT-- <br /> WORKERS <br /> ITHWORKERS COMPENSATION LAWS, L <br /> INIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED �` TITLE CEO DATE 06/27/05 <br /> n <br /> JC A'U Ir Cr.Ljl'.I_" <br /> NVH NA,EN + <br /> T <br /> ZZ <br /> S <br /> DEPARTMENT USE ONLY i1 <br /> Application Accepted ByDate 10A _T Area Employee ID# ✓Ye <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection B .� - =-� Dale �'6` 11 WAIVER Reeeived <br /> Destruction Inspection By �' Date Constructed Well Depth it <br /> COMMENTS ; / <br /> PE SC Received Check# Amount Date Permit! Invoice# WellID# <br /> Codes Info B ash Remitted Service Request# <br /> 3 Gr 250 9 50,00 o a ;�.) 'oc 2 <br /> EHD 43-c7-0❑E WEU PUMP PERMIT <br /> W6104 <br />