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CROSS STREEI�Af C'n n I�1:Ll YJr� APN (I/ PARCEL S12fLAND USE APPQCAmON# <br /> OWNERNAME PHONE <br /> ' OWNER ADDRESS - CRVISTATEJZIP 2-011 <br /> te..11 <br /> CONTRACTOR KK 1 K^ /Jd <br /> 41= " • 9 PHONE /Y� n`rJ���L_��- <br /> ' <br /> CONTRACTOR ADDRESS 20Q /�l1�yl TTrr'�Y+ EQ C, �#kYn CITYISTATEIZIP L rte.' C kl^ `Ern l <br /> I 1 i SUBCONTRACTOR & LAA-- ,n{�4 PHONE�aq! l;^ / <br /> SUBCONTRACTOR ADDRESS �-3 CO S- WirS vV GI YVI ,U t1 TV CITY/STATEIZIP <br /> LICENSE XC-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER EXPIRATION DATE If 1 /ZD(� <br /> GEOGRAPHICAL INFORMATION: Coordinates Y Township-_ Range_ Section_ <br /> INTENDEDDSE ❑ Domestic/Private ❑ IfrigatiordAgricultural ❑ Industrial ❑Water Quality Monitoring `G'Soil Sampling/Characterization lly{7.11 <br /> ' ❑ Public Water System to <br /> I Public <br /> Water Owner: ser ys am ame ono ame or Fhone NoLlmn.r <br /> TYPE OF WORK ❑ New Well ❑Replacement Well D Well AlterationlMadigcahon ❑ Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #ofbonngs ❑ Geotechnical. r.� dborings <br /> ❑ Out-0f-Service Well D Out-0f-Service Well Renewal ❑ Cross-Connectlon Repair <br /> ❑ New Pum Cl Pump,Replacement Ll Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> r Drilling Method 11Mud Rotary ��D Air Rotary Auger ❑ Cable Tool O Push Point ❑ Other <br /> Proposed Well Depth 7n <br /> 1218 ft Excavation /f In diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth It <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched D Steel ❑ Plastic D Stainless Steel ❑ Other <br /> Grout Seal Depth fl I�Neat Cement(94 lib bag/5-10 gal water) ❑ Sand Cement Sack mW7 gal water <br /> ❑ Bentonite(20%solids) ❑Other <br /> Grout Placement Method D Pumped ❑ Free Fall ❑ Other D Retardant/Accelerator(name) <br /> PEDESTAL Installed By D Driller D Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal Dimensions:Width R Length ItThick in ❑ Christy Box ❑Stove Pipe <br /> PWP- ❑ Submersible❑Turbine ❑Other HP Pump Set ft Standing Water Level R <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 <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAW <br /> MINIi�� <br /> UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS '/\-� <br /> SIGNED �� TITLE ��•� "dam DATE `--' l <br /> 115 E E D <br /> AN1 <br /> E V R N NT V <br /> i <br /> ry <br /> E ARTMENT ISE- Y. <br /> r Application Acceptetl"Sff'»1 MIal1� Date. 2d Area Employee ID#�2ft <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By �t Date WAIVER Received <br /> Sal Boring Inspection By ( Date l Constructed Well Depth R <br /> COMMENTS <br /> ' I - PE SC Raeelvad fRemlltad <br /> C.,eck#/ Amount <br /> Codes Into Dale PermlU Invoice# Wall IDI* <br /> B Service Re oast# <br />