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OWER ADDRESS O'7P ` � ect A4 A. CITY STATE/ZIP 40,c40 Co/Ctr/C� , C4 C75'i 7O N CONTRAC I'OR Zr_;rAb -1'e C &_ 4 PHONE //6/ - /a v 'o��•yb Co,,rRAC TOR ADDRESS /O �(J f/�I h�*I CITY/STATE/ZIP An gpyf//e, SUBCONTRACTOR PHONE. SUBCONTRACTOR ADDRESS CII(T,YYISTATFJZIP LICENSE %C-57 ❑C-61 ❑D-09 ❑other NUMBER ' "� ' t-5- F%PIRATION DATE __7 I3r C GFOGRAP111CAL INFORMATION: Coordinates X Y Tow e-= t n, INTENDED USE D Domestic/Private O Irrigation/Agricultural O Industrial ❑ rQlt WtinI 1 cn tion ❑Public Water Syystem — t I ! .. '' If di.^.elent Froin Owner: Water System Came ,cmtac .ame nr one. um e J withoiRXPI TYPr.OF WORK O New Well ❑Replacement Well ❑We]]Alteration/Modification a cs`,Hole p� s _ ❑Monitoring Well(s)_ 1t of wells ❑Soil Boring(s) — g �'GF,oltlec nua ❑Well Destruction ❑Out-Of-Service Well �10tTt=f?,��$fi �C'�4'elitlt��>$aI�� iv;ion ❑New Pump ❑Pump Replacement ❑Pump Repair ❑Cross-Conntxtion Repair WF.I.I.CONSTRUCTION Drilling Method ❑Mud Rotary ❑Air Rotary Auger Cl Cable Too] O Push Point O Other _ Proposed Well Depth_14L ft Excavation in diameter O Open Bottom O Gravel Pack/Gravel Size._ _in diameter U t\ ❑Conductor Casing in diameter 1 Conductor Casing Depth Well Casing Diametcr in Thickness/Gauge/ASTM Sched ❑Steel O Plastic ❑Stainless Steel ❑Other Grout Seal Depth ft O Ncat Cement("941h hag/5-10 gat water)' ❑Sand Cement __ sack mix 17 gal water El Bentonite(20%solids) O Manufacturer Spec%solids % 'same O Specs on File O Specs Submitted Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) C PEDESTAL Installed By ❑Driller Cl Pump Contractor ❑Other ❑Concrete Pedestal Dimenslons: Width (t Length___ _ ft Thick in q Christy Box ❑Stove Pipe PCMP ❑Submersible O Turbine 13 Other HP Pump Set ft Standing Water Level ft WELL DESTRUCTION ❑Open Bottom t ❑Gravel Pack ❑Uncased ❑Other _ Well Diameter in Total Depth R Depth to Water 111 ❑Casing to be Perforated from ft to A (- Sealing Material O Neat Cement(941h Lag/5-10 gal water) ❑Sand Cement .cock mix/7 gal water (Bentonite Pellets Tl ❑Rentonite(20%solids) O Manufacturer Spec%solids % Name _ _- ❑Specs on File O Specs Submitted Placement Method ❑Pumped ❑Free Fall ❑Other _ ❑Complete with Mushroom Cap ft below grade O Complete to Existing Surface Pad 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. / I S ` NIII MUM 2 OUR ADVANCE NOTICE.REQUIRED FOR INSPECTIONS } SIGNEu - -vTITI.E l ��Og,i a � , u�w Few wit . a.« 01 0 00 a0 rT. K as allalgl LL� ,aONIw k 1 31 rI Uat!R IILI �— swss n,s.s,■s. r wlsavna�s w.loos. ...1_2. A.- .NONA . K swCv NAMww.ar..1�m wi M2.0%. l,Ym I{A(O At/fef air QR •< f ma.I.010111111.O�1) A.r.N. 20A�000�2S t} Mme« SITEM AP �'� - �'im�..,w— 1 —rine ti W n J � ri+�r •ut^ 3 1 I 1 NJ� rwoa-.a,�DY!r_YJ4l.i..�d ' LY l N I'Il, N V Application Accepted By - Date 1 z� Arca 2l� Employee Ill# -` OUI .�>Grout Inspection By Dates �.(O—SPECIAL Well Permit----- Pump Inspection By _ - pate"-� ❑ WAIVER Received Destruction Inspection BY —_.. _. 'r. Date Constructed Well Depth It COMMENTS 6 3 _ Oe_/Y:SJf c _ of!( [ ►•Q- r!'� _- 1-1" t �!q -- _e.e a j!rL.7 "R� -tRGO ti V1� I -,AAA . !S L "tD