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OWNER NAME `2L/vr1 11e7-f-- n/Af7 10/VA C— PHONE <br /> OWNER ADDRESS CITY/STATE/ZIP <br /> FG / �1 <br /> CONTRACTOR _ C I NF y //f ONI LCL %,,Af PHONE �[7 10 <br /> CONTRACTOR ADDRESS P-V 65rY J 71/ 4 CITY/STATEPLIP / L%RLLJGAC 99-3 IF,% <br /> 1 <br /> SUBCONTRACTOR _ PHONE 1 <br /> SUBCONTRACTOR ADDRESS_ CITY/STATEJZIP <br /> LICENSE ❑C-57 ❑C-61 ❑D-09 ❑Other NUMBER EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range- Section <br /> INTENDED USE O Domestic/Private 0 Irrigation/Agricultmal ❑Industrial 17 Water Voil Sampling/Characterizalion <br /> O Public Water System <br /> Udifrereni from o..': Water yrtem ame --------Coninct ante V,Phone Nom er O <br /> TYPE OF WORK 0 New Well ❑Replacement Well ❑Well Alteration/Modification O Test Hole ❑Other_ <br /> 1 ❑Monitorin s numberofwSoil Boring(s)ellt numberofhorinS numberorbanalt <br /> B Well(s) 0 Ceotechnical y <br /> O Well Destruction 13 Out-Of-Service Well ❑Out-0f--Service Well Renewal \1 <br /> O New Pump ❑Pump Replacement O Pump Repair ❑Cross-Connection Repair C <br /> WELL CONSTRUCTION <br /> Drilling Method O Mud Rotary 0 Air Rotary O Auger 0 Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth ft Excavaticn in diameter 0Open Bottom 0 Gravel Pack/Gravel Size in diameter ^ <br /> ❑Conductor Casing in diameter / Conductor Casing Depth _tt `yl� <br /> Well Casing Diameter _ in Thickness/Gauge/ASTM Sehed ❑Steel O Plastic 0 Stainless Steel O Other <br /> Grout Seal Depth ft ❑Neat Cement(9416 hog/S-l0 gal water) ❑Sand Cement .tack mix/7 gal water <br /> 0 Bentonite(20%solids) ❑Manufacturer Spec%solids_% Name _ 0 Spas on File O Specs Submitted <br /> Grout Placement Method O Pumped ❑Free Fall O Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contreclor O Other <br /> ❑Concrete Pedestal Dimensions: Width_ R Length_ft Thick in 0 Christy Box 0 Stove Pipe <br /> PUMP ❑Submersible 0 Turbine 0 Other HP__ Pump Set ft Standing Water Level ft <br /> WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other <br /> Well Diameter in Total Depth ft Depth to Water ft ❑Casing to be Perforated from ft to ft <br /> Sealing Material [I Nut Cement(94 1b bag/5-10 gal water) 11Sand Cement .tack mix/7 gal water Bentonite Pellets <br /> O Bentonite(20%solids) ❑Manufacturer Spec%solids--% Name 0 Specs on File ❑Specs Submitted <br /> Placement Method ❑Pumped 0 Free Fall ❑Other <br /> ❑Complete with Mushroom Cap ft below grade O 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. I ALSO CERTIFY THAT MY REQUIRED LICENSE 1S <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMP SATION LA S. <br /> MI M 2 VANCE NOTICE REQUIRED FOR INSPECTIONS—PLEASE CALL(209)/953--7697 <br /> SIGNED d TITLE DATE <br /> a <br /> 'Sid A IK 11 <br /> i <br /> Y <br /> jJ <br /> N C <br /> EN AL EA! <br /> DEPARTMENT U5,5E LY II__ <br /> Application Accepted By Date �r+' d� Arae o) /E' Employee ID# <br /> Grout Inspection By li( 171_cDate 2 03 ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Destruction lnspwtl y Date--� Constructed Well Depth _ ft <br /> COMMENTS 1h^k'' <br />