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CROSS STREET 1*14r1(kA Kdr APN I's-SL7 C/t$ PARC EL.ITZE L>•rT U.nu vse nrrua.n,rvns q, <br /> OWNER NAME 771['�'/n,� rp 4 PHONE <br /> p' OWNER ADDRESS © ' R)p X l / L (J CITYISTATEILP� i <br /> CONTRACTOR kkelw&r ,PHONE (Z�' �)1 qW-1345. <br /> ' CONTRACTOR ADDRES1S( 240 414 krarrr 1CITYISTATEIZJP tflc4 i'pn / NT S ZOOS <br /> SUBCONTRACTOR V 4 �2 1 J(1 I'l <br /> ' 3� b PHONEA04) 20-9u <br /> SUBCONTRACTOR ADDRESS C(tok (A( CITYISTATE/ZIP C4"+VA ,4 <br /> i Zt 5- <br /> LICENSE 67 Ll C-61 II D-09 ' 011ier NUMBER �✓-W EXPIRATIONDATE <br /> ' GEOGRAPHICAL INFORMATION: COordlnatesX V Townshfp_ Range_ Section_ <br /> INTENDED U5E D DomestlGPrivate f 1 frriga9on/Agricultural rl Industrial It Water Quality Monitoring (Soil Sampling/Characterization <br /> u Public Water System // <br /> If dlaerenf firm Owner. a er ys em ame on a Number <br /> TYPE OF WORK D New Well I Replacement Well I! Well AlteratlonfModlfication i Other <br /> q of Eodnps Geotechnical qol Eodnes <br /> Monitoring Wells) #or wells rl soil Boring(s) <br /> O Out-Of-Service Well I I Out-Of-Service Well Renewal l! Cross-C nnection Repair <br /> t New Pump n Pump Replacement a Pump Repair i i Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method XMud Rotary I I Air Rotary (Auger Il Cable Tool I.I Push Point I! Other <br /> Proposed Well Depth '5D—15 it Excavation Ll—8 in diameter I7 Open Bottom II Gravel Pack/Gravel Size In diameter <br /> ' n Conductor Casing in diameter I Conductor Casing Depth it <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched ❑ Steel Plastic !.! Stainless Steel II Other <br /> Grout Seal Depth ft Neal Cement(94 Ib bagl5J0 gal Water) Sand Cement sack mfx/7 gal water <br /> ' <br /> i! Bentonite(20%solids) Other 1 <br /> Grout Placement Method &umped o Free Fall :1 Other I Retardant I Accelerator(name) <br /> Installed By rI Driller 17 Pump Contractor ❑ Other <br /> I.I Concrete Pedestal Dimensions:Width it Length it Thick in !I Christy Box I1 Store Pipe <br /> ' PUMP ❑ Submersible l7 Turbine LI Other HP pump Sel it Standing Water Level it <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 LAWS. <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS _ <br /> SIGNED TITLE �sbt !.T f `� � �I S� DATE <br /> 1 <br /> U <br /> 7 <br /> W <br /> 1 ------ ------------ <br /> DEPARTMENT USE ONLY <br /> Application Accepted B� --"- Dale Area �,_f Employee IDO <br /> Grout Inspection By Date SPECIAL Well Permit <br /> ' Pump Inspection By - ate WAIVER Received <br /> Constructed Well Depth <br /> Soil Boring lnspeptiDate onsN <br /> on ' .- — <br /> COMMENTS ` _ <✓ Lc A j�'2!1 R4-lie%" <br /> P <br /> PE SC Received Check#I Amount nam _ armW <br /> _ _ Invoice# Well ID# <br />