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� CONTRACTOR ADD� L/.:�� 1.1•%�� � � y lSraTeJZIP t/ <br /> I <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITS'JSTATOZIP I ' <br /> LICENSE 13,C-57 fH C 61 ❑D-09 ❑Other NumaER $ EXPIRATION DATE rJ' <br /> GEOGRAPHICAL INFORM.TION: Coordinates X Y Township Range Section <br /> INTENDED USE mesticlPrivate ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil ampling/Characlerization <br /> ❑Public Water System f <br /> y If diM,em from 0—,: aur System Name Contact Name or oneNumberI ` <br /> TYPE OF WORK New Well ❑Replacement Weil ❑Well.Alteration/Modification ❑Test Hole ❑Other <br /> ❑Monitoring Well(s) number of wells ❑Soil Boring(S) —tuber of bodags ❑Geotechnical "°tuber of borie6K p <br /> ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal C� <br /> • ew Pump ❑Pump Replacement ❑Pump Re it ❑Cross-Conneclion Repair <br /> WELL CONSTRUCTION r <br /> Drilling Method 5"1-ud Rotary ❑Air Rotary ❑Augef ❑Cable Tool ❑Push Point ❑Other <br /> !�w <br /> E Proposed Well Depot CIO R Excavation 12 in diameter ❑Open Bottom 21ravel Pack J Gravel Size--!Y in diameter � <br /> ❑Conductor Casing . in diameter l Conductor Casing Depth It C <br /> r <br /> Well Casing Diameter in Thickness/GaugeIASTM Sched� � �1i7:(� ❑Steel Q astic ❑Stainless Steel ❑Other <br /> p Grout Seal Depth-_/.0.0 1t O Neat Cement(941b hug/S-10gat wafer) ❑Sand Cement_- 514 ,ruck mixt 7 gal water <br /> 0 Bemonite(20!solids) ❑Manufacturer Spec/solids % game <br /> ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method iifmped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL installed By OFuriller ❑Pump Contractor ❑Other <br /> • oncrete Pedestal Dimensions: Width ft Length H Thick in ❑Christy Box ❑Sfvve Pipe <br /> PUMP submersible ❑Turbine ❑Other HP Pump Set 11 Standing Water Level_ A) R <br /> WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased 0 Other <br /> L Well Diameter in Total Depth R Depth to Water R ❑Casing to be Perforated from ft to R <br /> Sealing Material ❑Neat Cement(94 1h hag/5-10 gal walerJ ❑Sand Cement suck in&17 gal water ❑Bentonite Pellets <br /> I ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑SpecS on File ❑Specs Submitted <br /> Placement Method ❑Pumped ❑Free Fall ❑Other <br /> ia Q Complete with Mushroom Cap 1t 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 ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL- <br /> WORKERS COMPENSATION LAWS. <br /> M NI M 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED �- � 7i7?r TITLE r DATE <br /> I Ah + k�-'A-A) I I I <br /> Q <br /> j SL <br /> li,40 CJ 1 j <br /> 557�ibl <br /> yfrr t. �hf+� <br /> ' `O <br /> 6 - TV- <br /> -Aj <br /> ' f DEPARTMENT US O LIn Y _ <br /> t j Application Accepted By r Date Area --, _ Employee IDH - <br /> Grout Inspection Sy Date D2 ❑ SPECtAL Well Permit <br /> ((('''���;;; Pump Inspection By Date 11 WAIVER Received <br /> ' Destruction Inspection By Date Constructed Well Depth ft <br /> IF j. COMMENTS Y ] Q r P,-" Q u f <br /> - PE SC Amount ! Received Permit! <br /> ECodes Info Remitted ash By Date Service Request H InvoiceN WeIIIDH <br /> C6 <br /> k <br /> 1 EHD43-02-006 --- <br /> f ` <br />