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_ I V YOmle m Owner <br /> rt <br /> Ifdi fferemfrom wnev ater ystem ame Comact Name or Phone Number <br /> �\ A <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modi. Ion ❑Test Hole ❑Other _ <br /> ❑Monitoring Well(s) numberofwelis 0Seil Boring(s) numberofborings 0Geotechnical <br /> ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal <br /> ❑New Pump ecmp Replacement ❑Pump Repair ❑Cross-Connection Repair <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched - ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth ft ❑Neat Cement(941b hag/5-10 gal water) ❑Sand Cement s <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids—% Name ❑Specs on File <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑Other <br /> ❑Concrete Pedestal Dimensions: Width_ ft Length_ft Thick in ❑Christy Box <br /> PUMP Submersible ❑Turbine ❑Other HP—V-2= Pump Set_ It Standing.Water Lev <br /> WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other <br /> Well Diameter in Total Depth R Depth to Water ft ❑Casing to be Perforated from <br /> Sealing Material ❑Neat Cement(94 lb bag/5-10 gal water) ❑Sand Cement sack mix l 7 gal water ❑Bentonite Pell <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File <br /> Placement Method ❑Pumped ❑Free Fall ❑Other <br /> ❑Complete with Mushroom Cap ft below grade ❑Complete to Existing Surface Pad <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORD. <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUI <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLI, <br /> WORKERS COMPENSATION LAWS. <br /> .- MINIMUM U ADVANq ICE REQUIRED FOR INSPECTIONS- PLEASE CALL(209)9: <br /> SIGNED C TITLE ` tY\P ` e-LV 1 DATE�� <br /> E F <br /> DEPARTMENT USE ONLY a <br /> Application Accepted By Date a 7�1 UJ Area 4 Employi <br /> �. Grout Inspection By Date ❑ SPECIAL Well Pern <br /> Pump Inspection By - Date s 0 / ❑ WAIVER Received <br /> Destruction Inspection By Date Constructed Well Depth <br /> COMMENTS O <br /> PE SC Received Checldt/ Amount Date Permit/ Invoice# <br /> _ Codes I Info By Remitted Service Request# <br /> a few g q oS" <br /> EHD 43-02-006 MASTER R <br /> 12/6/2002 <br />