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O <br /> CROSS STREET f1 11 -1 tt A/IP�N (7b 1 230 Q � PARCEL SIZE Ir-LAND USE APPLICATION# m <br /> OWNER NAME UI U C�CII L7� lJ�+-k 1 n (�L PH/ONE 3 G 7 7/7 G, <br /> ' OWNER ADDRESS ZA Q 7 2 ll LCGk-4(j +`-O CITYISTATEIZIP L?/}//-I— C4- 9s--672L <br /> CONTRACTOR K U —)t;,I I )21II I� PHONE G <br /> CONTRACTOR ADDRESS O —,Y /0l/� � CITY/STATE2 � <br /> 1P I�rJ Cz� <br /> ' SUBCONTRACTOR 65/-6- �.�4 / // /"�` -f�/L/ PHONE <br /> SUBCONTRACTOR ADDRESS �Tl' �y3-81 au—:0 CRYI9S9TATE71P <br /> ' LICENSE C57 ❑ C-61 ❑ D-09 ❑Other NUMBER qr"3 qp� •EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range_ Section_ <br /> INTENDED USE ❑ DOmeSUC/Private 0 IrrigationtAgricultural ❑ Industrial ❑Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> ' ❑ Public Water System <br /> t[diPublic <br /> from Owner. aer am ame on cName or Phone Number <br /> TYPE OF WORK ❑ New Well Replacement Well ❑Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Weil(s) #of wells ❑ Soil Borings) <br /> #ol Wdnss ❑ Geotechnical #eftonngs <br /> ' ❑ Out-Of-Service Well ❑ Out-0fService Well Renewal ❑ Cross-Connection Repair <br /> ❑ New Pump ❑ pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ❑ Mud Rotary ❑Air Rotary ❑Auger' �/❑ Ctra'ble Tool 11 Push Point ❑ Other Proposed Well Depth 06 ft Excavation�—in diameter ❑Open Bottom ❑ Gravel FacWGravel Size In diameter <br /> ❑ conductor Casing in diameter / Conductor Casing Depth it <br /> Well Casing Diameter L in Thickness/Gauge/ASTM Sched Steel ❑ Plastic ❑ Staintese Steel ❑ Other <br /> ' Grout Seal Depth15jQ _ft ❑ Neat Cement(941b bag(5-10 gal wafer) Sand Cement �O•3 sack mixl7 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed Ely Driller ❑ Pump Contractor ❑ Other <br /> ' ❑ Concrete P d sial Dimensibns:Width it Length it Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP ❑ Submersible❑Turbine ❑ Other HP Pump Set ft Standing Water Level ft <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. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVF WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPE ON LAWS. <br /> MINI 24 HOUR ADVANC NOTICE REQUIRED FOR INSPECTIONS <br /> r <br /> ' SIGNED TITLE O��— DATE / � /L <br /> TTTI <br /> ' - E R NM N7 <br /> Sl1 <br /> " <br /> Area EmployeeID#� <br /> Application Accept B ate�l <br /> Grout Inspection B i pate I SPECIAL Well Permit <br /> ' Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth It <br /> COMMENTS <br /> ' PE SC Received Checktil Amount Date Permitl Invoice# Well ID# <br /> Codes Into B Cash Remitted Service Re uest# <br />