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OWNERADDRESS [' / /�//CrT1'/STATE/ZIP v <br /> CONTRACTOR 1,1(y1 z/ 6Af,}l- S;hz Ol (@ /1fL �A [/ 0&0 PHONE S l 9/J <br /> CowitACTORADDRESS AdOW" aL-�c L.ee� �f /�7 CITYISTATE/LIP �M/fj�iyJ LSI <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS_ CITYISTATE/ZIP <br /> LICENSE 0 C-57 OC-6i 0 D.09 )9B0ther zia—aiL NUMBER 7 311 3 .L EXPIRATION DATE S - <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township _ Range__ Section <br /> INTENDED USE omestic/Private O Irrigation/Agricultural O Industrial 0 Water Quality Monitoring 0 Soil SamplinglCharecterization <br /> 0 Public Water System <br /> Ifddervatirme wnm:- Water System Name anted amaor707T.—Mlirr <br /> TYPE OF WORK 0 New Well 0 Replacement Well O Well Alteration/Modification 0 Test little 0 Other <br /> ' 0 Monitoring Well(s) nvmberofwells 0 Soil Boring(s) numberafbW1r.P 0 Geotechnical numberarbadags <br /> 0 Well Destruction 0Out-Of-Service Well ❑Out-Of-Service Well Renewal <br /> 0 New Pump >litflunipiReplacement 0 Pump Repair 0 Cross-Connection Repair <br /> WELL CONSTRUCTION <br /> Drilling Method 0 Mud Rotary 0 Air Rotary ❑Auger 0 Cable Tool 0 Push Point 0 Other <br /> Proposed Well Depth ft Excavation_ in diameter 0 Open Bottom 0 Gravel Pack/Gravel Size in diameter <br /> 0 Conductor Casing in diameter / Conductor Casing Depth _R <br /> Well Casing Diameter in Thickness/Gauge/ASTM Schad 0 Steel 0 Plastic 0 Stainless Steel 0 Other <br /> Grout Seal Depth ft 0 Neat Cement e94 1b bag/5-10ga/water) 0 Sand Cement sack mix/7 gal water <br /> 0 Bentonite(200/9 solids) ❑Manufacturer Spix%solids_% Name _ 0 Specs on File ❑Specs Submitted W <br /> Grout Placement Method 0 Pumped 0 Fra Fail 0 Other_ 0 Retardant/Accelerator(name) <br /> PEDESTAL Installed By 0 Driller 0 Pump Contractor 0 Other <br /> 0 Concrete Pedestal Dimensions: Width_ ft Length_ft Thick in 0 Christy Boz 0 Stove Pipe <br /> PUMP Submersible 0 Turbine 0 Other HP r PumpSet-4 II Standing Water Level 3— 11 <br /> WELL DESTRUCTION 0 Open Bottom O Gravel Pack C Uneased 0 Other <br /> Well Diameter in Total Depth ft Depth w Water ft ❑Casing to be Perforated from ft to N <br /> Sealing Material 0 Neat Cement(94/6 lag J5-10ga1 muter) ❑Sand Cement rack mix 17 gal water 0 Bentonite Pellets <br /> 0 Bentonite(20%solids) 0 Manufacturer Spec°A solids % Name 0 Specs on File 0 Spws Submitted <br /> Placement Method 0 Pumped 0 Free Fall 0 Other <br /> 0 Complete with Mushroom Cap ft below grade 0 Complete to Existing Surface Pad <br /> 'I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN m <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 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> 1 UM 4 VANCE NOTICE REQUIRED FOR INS ECTIONS— PLEASE CALL(2O9)953-7697 <br /> SIGNED � TITLE DATE <br /> W - 1 All <br /> -figI <br /> to � <br /> O U <br /> N <br /> Ell <br /> DEPARTMENT USE NLY 3/ <br /> Application Accepted Hy_ ((Y Dale C'� Are, o�b Employee IDk s ° e <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> ' Pump lnspa.•tion y 6 ,moiC Date 2"IeS- ❑ WAIVERReceived <br /> Destmction Inspection Ry Date Constructed Well Depth R <br />