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1 OWNER NAME_ 6-92i4Nt r¢.- CANS rx'/Lr7A DRESS <br /> CITY2w_ PHONE-I <br /> CONTRACTOR f<<��-1/�/.s17�f L06.IL'– ADUR�ES/S�/L �{ L , t--7�'" <br /> 1 CITY2IP N S' S Z�� PHONE ! b – I3��� C-57 LICENSE#y l_Z-EZ cP DATE_T/:0_'__ <br /> 1 GEOGRAPHICAL INFORMATION: COORDINATES X_ Y_ TOWNSHIP_ RANGE— SECTION <br /> TYPE OF WELL: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑OTHER <br /> INSTALLATION: ❑WELL SYSTEM REPAIR ❑CROSS-CONNECTREPAB2 ❑VAPOR EXTRACTION WELL# <br /> 1 TYPE OF PUMP: ❑ NEW ❑REPAIR H.P. DEPTH PUNIP SBT FT. FIRST WATER LEVEL <br /> ❑OUT-OF•SERVICE WELL )Q GEOTECHNICAL# L ❑SOB.BORING ❑DESTRUCTION: <br /> 1 (F ! R-VqtT <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION <br /> n <br /> ❑INDUSTRIAL 11OPEN BOTTOM 49.EXCAVATION DIA Y-4 CONDUCTOR CASING DIA <br /> ' ❑DOMESTIC PRIVATE ❑GRAVEL PACK/SIZE— WELL CASING TYPE WELL CASING DIA <br /> ❑PUBLIOMUNICIPAL ❑DRIVEN GROLITSEALDEPTH SPECIFICATION <br /> ' ❑IRRIGATION/AG OTHER GROUT BRAND NAME /F )A1 60 <br /> ❑MONITORING GROAT SEAL PUMPED: ❑YES ❑NO <br /> 1 ❑CHRISTY BOX ❑STOVE PIPE CONCRETE PEDESTAL BY DRILLER: ❑YES O NO <br /> APPROXIMATE I'L DEPT N I 5-- <br /> PROPOSED <br /> -PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY_AIR ROTARY_AUGER K_CABLE OTHER <br /> ' I 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. I ALSO CERTIFY THAT MY C•57 LICENSE IS CURRENT <br /> AND ACTIVE WITH THE CALIFURNIA CONTRACTORS STATE Ll:ENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKMAN'S C <br /> COMPENSATION LAWS. <br /> I 7 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS 3/b <br /> SIGNED TITLE Szy /� <br /> �/LOi�55IONN"415ATE <br /> 1 r <br /> i - - <br /> a � <br /> rs <br /> E g� <br /> DEPARTMENT USE ONLY <br /> Application Accepted.B Dat, Arn� EMPID# <br /> 1 Grout Inspecti By ter^ a _Pump Inspected By _Date <br /> Deswctian Inspection By Date <br /> 1 <br /> COMMENTS: ��,�-•----�` / ��n t� ,�7iI �/// /✓ <br /> r' <br />