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i 7 c Nl <br /> WI-11 II{::�IItU(;'1'it3�l {'I:I�IUII'I <br /> I�ucuCWAiufSY:.nll l Iv+:�,:, <br /> 3Ar1JOAomHCuunrr EIAIMUN+EMAI.I it At 1110fl•ARIPF fit Call!htrvriNTHEL 1•STocRTun CA 95202•(209)466J O <br /> ItION-2EFUNPAULE PERA7IT - 1-At I (rllu II:,J ra'+l l u..?l: rl, �� _ VXMIMS I YEAR FROM DATF ISSUED <br /> Jon Aooaess.951S1its1-ILgllun'1' _ curer+r / L_ <br /> Dee Alk"r ),5241) <br /> GRD34S1Rtet 10L11t.1.lKtt5111ee Rd. APN_ 9-C) fj <br /> �ryt , PARatI$LtE�1 AAD USE APFl1CAilOtl fl— _ D+ <br /> O.'.7:LR, P(it.F. it e rn 1'_ I'1I0::E <br /> O':n:EHAr,unf34_•_>1�I tl ( J oi. ((t 111 (1. a'(\ ' r l tl 1 T <br /> --- --err/srATElzrp�(y1 tt llftr li_ `-- <br /> Contawom WDC FXDIOTAtion and Wells PHot.E 800.873.8073 _ <br /> CoulmoTORAtioaE33 9580 C OUuty Road 9313 _ CIIvISTAII/lleZU11101:T, 'RlifurltlR,95698 _ rl <br /> C-S7VALLOR.LL11.17 LrefllsE NU!19E � � Exa1RAilDir DAZE W _O 1 !' ! <br /> PERFORAIID.'ICO.'IIRACIORS•1DC 1;X7lOr8t ion and Wells_ _P110�4 500.873.5073 y <br /> PERFORA1109COMIACTORADORE43 9580 Count Road 93B cnyisTATvzq, Zamora,CA,_JSG98 <br /> Lf C•57 WO Dong License NOmberI(;�pj ZL� E>phal on Dale <br /> Bureauol AYohcl,Trbacro and Fltearms-Users of If.h F> osmas a <br /> He Number r' EsySauonOato__ <br /> CHP Hazardous Idnieual lrnnspomabon for Esp'ostvas License NumhM Exy'maon Dale -! <br /> San Jo311u n County ShenfFCoroner Explosives App!ical;on and Penni[ License flwnber_ Exp:ralon f!alo <br /> _ Calfom a Occopelronsl SafclyHeaah•Blaster _ License Number Eap:,atwn Date 1 <br /> (j[>JSO:/FOR Dwitucrim ❑ Dry ❑ HoroMcemenl Mil ❑ Caved In 0 P,1 Wet KJ Inactive C) Test Ho:a <br /> Detected I Suspected Wall WalerContaminail(s _ <br /> )__ 1 C-1' <br /> Ad jac ant properly v.+lh contalnlnallon(Ad(ress) 5 <br /> Known SO.I/Water contaminants at adjacent pcoprlty I� <br /> EMS 1140 VICE C0.'737RUCngUPJ1A1la ❑ Optn D;Aom 11 GtasHPack 0 Uncased Er Otter VAYriots111 C ' <br /> %'loll Log coprallachci C3Yes 0 I,b GroulSeal 0 No E7 Yas___Rbs!o:rgrardtvlacelbgs) HoleDtameler__ 10`0e3 v <br /> Well Conduclor Casing 0 Yes ❑ ice DeplhoMooduclor Casing_ _9bJs Diameter of Conductor Casing _Inches <br /> 1'/ell CSsing Dlemeter_�_irrhrs Tola)Depth_ 250_h Drplh to Waler_ R Di plb of Caling ,_ A Ws <br /> Scaling 6falertal from .?-'i[, R bgs to__`? 0 bps Filter Material `A-'l _franc 5 It bill;to 1 R bps . '•1 <br /> Wr�/llcasingtobapetoia by9naofflit follovyIn rinihs ads:__ from \;N4n.(t itbasto [�C.� It tills <br /> IT Mills Knire ) Nuniberolculsavery <br /> ❑ Exploslvos❑ Delonating cord 0 sv(Ih pfojeclles awry R ❑ y.Nhoul pfoleceto ' <br /> ❑ Other— <br /> 0 Detonating cord and boosters LlWlhplo;eddesovery_ it ❑ %mth0Utpr0)ecbf0 ( 7 <br /> scaling Material NoatCement(9,4lbbW9/"gal r:eterj Sand Cement 7p_sac%mis/7 gal water DeifonlloPellets <br /> Denlonilo(zo%solids) ),IsRllackmarSpec'kso'ds_A Nalne Spars on File SpecsSubnulted <br /> Placement Method CI'Lxnped ' Free Fal Other_ _ <br /> Seal Complelton Comptolosvilh Mushroom Cap, 3' 's n bgs Comp:cle to Existing Surface Pad "f <br /> 1 HEREBY CERIIFY THAT I HAVE PREPARED 711IS APPLICATION AND IIIAT THE WORK WILL DE DONE IN ACCORDANCE YBIH SAN <br /> JOAQUIN COUNTY ORDIIIAI[CES,STATE MIS,AND RULES AND REGULA11ONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND AC11VE W11H THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD A[ID TIIAT I Aid IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. T <br /> 0!tI16111r, i•11hit 111 AtIVAflc.1.NO IRd 1(I U1111(1 it 11?1(Ili,ii•l I.IluiI (7 <br /> ,,. Field ope:aci�nts Manager , <br /> CO:iiMCTOAb S:ONAIUAE — _ _ Ti1LE DATE S/La/11 <br /> it <br /> r <br /> i DEpA RTAIENI USE ONLY / •� <br /> App!!calon M.cepted[77�— Dale I Arca [ •� t 6>N�AO'r,. _ r <br /> Desimel'on Inspection By_ _� Dale _ Emp.oyeo 101 <br /> COMMENTS <br /> PE SC Rocoivod C OtlookN[ Amount parmlV <br /> Cod-7es Into 0 Date Cash _ Remitted S¢lvlca Requesi fl Invoice U Well 10.V <br /> 3 <br /> E liD 1a 03 ROLL DESTRL.011Oti PEMM7 <br /> 20'5'07 <br />