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(/_/ / 'VAK"L JILt ' ANU UJt APPLIGArIUN P <br /> OWNER NAME 3, N 0 !�ej-t �- V -�-- L.PHONE L ` 2-() y <br /> L <br /> OWNER ADDRESS A;-)"F CINISTATE/ZIP <br /> CONTRACTOR �Cdw4 PHONES3//— Z1 <br /> � t---5' <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP �,/ /F�jL/��& <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATEE//nZIP <br /> LICENSE >.-,-C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER3.2 73�S EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y _ Township Range Section <br /> INTENDED USE —_o4 Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization S"Pt1 <br /> ❑ Public Water System <br /> fIf different from Owner: er ys em Name Uoritact Narre­-c-r?T;6-ni Nurriber <br /> f TYPE OF WORK -.L New Well ' ❑ Replacement Well n Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells U V of borings Soil Boring(s) ❑ Geotechnical #of borings <br /> ❑ Out-Of-Service Well 0- Out-Of-Service Well Renewal ❑ Cross-Connection Repair 1 <br /> . ew Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casin <br /> WELL CONSTRUCTION <br /> i <br /> Drilling Method y�Dud Rotary ❑ Air Rotary U Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth 7-AO —ft Excavation 1in diameter U Open Bottom ><Gravel Pack/Gravel Size in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter 1 in Thickness/Gauge/ASTM Sched Z-� 11 Steel >47PIaSt1G U Stainless Steel ❑ Other <br /> Grout Seal Depth Ln� ft n Neat Cement(94 lb bag/5-10 gal water) Sand Cement sack mix17 gal water <br /> F Bentonite(20%solids) ❑ Other <br /> Grout Placement Method-'05�Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By riller ❑ Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP �eSubmersible❑ 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 /> I WORKERS COMPENSATION LAWS. <br /> r MINI UM 4 HAUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL(209)953-7697 <br /> SIGNED iu�.. TITLE C)c"jil'r-k DATE �I -11) <br /> I � <br /> 1 <br /> r f. <br /> - A UIT <br /> SA, j0T <br /> C <br /> E <br /> if -- _ - <br /> ARTMENT /U/SE ONLY C� <br /> Application Accepted y ate I++21-2— Area 60 ! Employee ID#- <br /> Grout Inspection By Date l D ❑ SPECIAL Well Permit <br /> Pump Inspection ;4"15Date / ❑ WAIVER Received <br /> Soil Boring Inspection By - Dbte Constructed Well Depth ft <br /> ANTS Q r <br /> PE SC Received Check#1 Amoun <br />