Laserfiche WebLink
V:1VJJ J1 RCC1 [e--(Z HrIV !/►✓ vxv -fir S r"L;LL JILL- /^,I' / LAND U5E APPLICA <br /> TION iF y m <br /> (OWNER NAME PHONE <br /> IO'NNSR AOLNESS _—.. CITYISTAT_IZIP <br /> CONTRd'.CTOR / ----- - PMOK,I <br /> CONTRACTOR ADDRESS _ s - �� [NC`,/ CITY/STATE/ZIP ��4,;z <br /> i <br /> SUBCON I'KAC fOK PI IOYE <br /> SUBCONTRACTOR ADDRESS 'CIITYISTATEIZIP <br /> LICENSE ,Q,Z'r D C-61 U D-09 D Ojter NUMBER �i �y� EXPIRATION DATE <br /> — - -- -__.__. <br /> GEcGR.,•,PHICAL INFO;iIrAmwc Coordinates X Y Township Range Section <br /> INTENDED USE � &rrestic!PGva_e 0 lcigation/Agricultural ❑ Industrial 0 Alater Quality Monitoririg ❑ Soil Sarnpling/Character:-aticn v <br /> D Djbl'c Water System <br /> I If c.' rert:rwn Ow.•ier ,a-er SystemNarie Name o: ^c-lo Nurrccr <br /> TYa7 or WORK C Naw VJcll Gi,�cplaccanent W,-Il D Vtre:l Alleration/Moaif•cation _ Olhcr <br /> L Monitoring VJeII(s) #of wells U Soil Soring(s) ++or born,s G@oleGan:Cal �- of bor'rgs <br /> !- Out-O`.-Sorvice,,/ell 0 Out-Of-Sarvice'lcil Renewal 0 Cross-Connection Repair <br /> C New PJ'nc 0 Pump Replacement ❑ Pump Recair U Rase bVell Casing <br /> WELL CO%STRUCTION� _ <br /> Drilling Method ✓`Aud Rctay U Ai-Rotary L Auger 0 Cahie Too! f7 PLSh P& t ❑ 011ier <br /> Proposed Well Cepth ft Excavatio —___tI_ in diameter U Open Bottom. ;7 Gravul PacWGravei SizeqV-6 in 6ameter <br /> Cor.CLc.or asog in diarr.eler / Ccnduotur Casing Oepth ft <br /> Well Casing Diame-e' <br /> iq. Th'.ckness,'Ga.igelAST.%1 Schec f GD COPT ❑ Sluci as6c C Stainless Steel 0 Other <br /> Grout Seal Depth C Neat 03ment(g4,b bag/5-700 yal wader) U Sand Coment sank mW7 gal water <br /> entazlte 7(2o/ solids) ❑ Other <br /> Grout Placement Melted ped r] Free Fall ❑ Other -� 0 Retardant/Accelerator(,carne) — <br /> PEDESTAL Installed By U DrTer Parnp Contractor U Other <br /> 0 Concrete Pedestal Dimensions:Width_._ ft I_erpth _— ft Thicx :n ni Christy Box 0 Stove Pipe <br /> +Pufrr, 0 SubmusiblcC Turbinc Other _ .-IP Purrp Set _ ft -Sanding Vdaler Level ft <br /> I HEREBY CERTIFY THAT I PAVE 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 PAY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT.( AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MIN MJUM 24 HOUR ADVANCE NOTICE RqPUIRED FOR INSPECTIONS <br /> SIGNED TITLE DATE <br /> / -- -- -- - <br /> 1A P <br /> 1 I <br /> JI � <br /> w. <br /> I <br /> 1 _ <br /> i 1 <br /> 1 _ <br /> 1 <br /> Fi`li <br /> 1 I _ <br /> C <br /> — c u <br /> VI 0 Jl NTNq <br /> �- <br /> LL- <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Dale Area y°I Enplcyoo lGn14 ewk 0�Oti <br /> Grout rspection ByDatc SPECIAL Well Permit I <br /> Pu:-np inspection By Cate WAIVER Received <br /> Soil Boring inspection By _ _ _ _. Dato Constructed Well Depth ft <br /> COMMENTS, <br />