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02/24/2004 09:27 2094683433 FIFTH FLOOR PAGE 02 <br />Sn11 J W QUIN COIlhTV ENVIkpVhtlthT <br />NON-KLpUMDABLE PERMITr1l. , 2Q9) tDEPnkTAattYT <br />306 8 WEBER Avg 3 STOCI(rON CA 95202 . (Z09) 469-uzv <br />JosADDAECg <br />/f C 953.7697 Ppp; lN&PECI.10\S ""AES l YEAR PROM DATE ISSUED <br />�c %05' �-7-- / <br />CROS STREET p CITY/ZtP 5767 k- 5� D <br />OwivERNAVJE 8�� APY PA�79RCELSIZE <br />OwNfiRADDE9R R3� o PRONE .0— <br />ronTR..c7oR <br />�ur $L(j7� CClry/SrATVZl1• A9 of <br />GOTTR.tCTOR ADDRE.vS ✓ � j %I/ n � �� PBONE iX%� <br />u inc � Jr <br />SUBCONTRACTOR C19Y/ST%Tvzlk. <br />r <br />SUBCONTRACTOR ADDRSg's PHONE - <br />UcErrs! O CS7CITY/STATEMP <br />O CGI D moo Rfn.t.-- D <br />rveMBER �'d ExP[M tT ONDATE <br />RApJI <br />CCOCJt:N,lN�W11ATlOh: CuordlRntat X <br />INT'INDr.D Use ❑ Da V Towttaht <br />meStidFrlvalo D ItrlSuLkI lAgricnhurd BSc Seedna <br />C, Public WaterSvotcm ❑ laduelrizl D Wtucr QuuJity Monitorin • ' <br />Irdlrtettr t IWI i v or. b O Soil Sumpli tarChoruaterication <br />NWUer ysttm <br />7YPGOFWORK OW Repl+tanent well13 Well Alicmrratri <br />on/MOdiCrcutionDMongu(;) <br />F•mca oar, um a <br />numberor.ztis O Tea Hole D Other <br />D Well Destruction D Sail Borings) narxb-4fbo&p <br />New 00 <br />D Golechnical <br />eumeervrbtmrro❑ruPunt Rc laacrl)= ee0 Out -Or Serviec WellWEILLCO STRec7jC'r qpumRc air Renewal <br />O Crost•Conncetion Re DrJlling Method 0 Mud Rota Air <br />>7 r 0 Air Rotary d Au&w Proposed Well Depth 01 d Cable iaal O Pooh Paint �j Other_�C , /90!/�9Q/GE- <br />JZ Excavation_( in diamOter <br />❑ Conductor Curing _in diameter !Open Bottom O Grovel Paelt /Cra <br />Well <br />Caning Diameter Conductor CA ing Depth Gravel Size is diBtncter <br />— in liticlataylGattgcrASTM Scheel It <br />GrnutSeal Depth R ��� D Stccl D Plnatio D Stuielosa Sloel D Other <br />D Ncat Ccrh (9P /5 &g/ S.IO J.ro/ tvorvry <br />A Bentonite (20%,,.11141 ) O Manufuctutcr Spet "f solids Y Nmne ❑ Sand Cement <br />Groes PJaeoment Method D sock rusk 17 6a1 wntu <br />Fumpcq ❑ Free Fall 0 Outer 0 Specs on pile D Specs Submitted <br />PEDIiSTAL In al[nd - 0 Rcwrdant/Aceelcr;rtOr(name)_„ <br />--�--�Y Q Driller E3 Pump Coatroctor <br />Concrete PedcWnl Di --loan W idN 0 Other <br />d Suhmmable — fI Lagxlh B Thick_ In <br />Q Turbine D Other O Cnr9ety Bntt D Stave Yrye <br />WEra pEttRcerJON ' r'Bottom 111111-1 ''NPS^ AtOtPStr <br />Well Dia —it Standing WaterLcvol <br />D Gmvel P.nek Un D cased D Outer � <br />Sea)ing hlatvrla) O Neat Ccmotu Total Depth Il Depth to Water <br />(2//bbar /S.Id .p/Np�f ft OCoolnSidbePerforatedirram Il to <br />b ) D Said Cctncnt ,,ruck ntt> / 7 I water ft <br />O Bentonite (20•/ solids) D ManufucturrrSpeC ra t011CL 8a D Scalonitc rollers <br />P1a00reent Merbed 0 pump % Nume 0 specs on File E3 Syccs Submitted <br />❑ Free Ful! O Other <br />D Complete with J UAMOm Cap U below rude <br />I RIPE" CERTIFY THAT I HAVIK PREPARED TyeAPPLICATION nVp THAT Tyk WO 221010 to Existing Surface Pad <br />CUnl;.E I ACCORDANCE <br />N COD Ty ACTIVE <br />WITH T1r STATE LAWS, AND RULES AND ►IECULATIONS. I ALSO CERTIFY THAT IYfY REQUIRED LI%nTII SAN <br />CENSE 1S <br />W RRq\'I' AND ACTIVE w1TN TIlE CAI I7+ORVIA COVTRACFORS STATE <br />LICE -VSE BOARD ADD TtIATRKWILL BE OIO A IV CO EQUI WITH <br />ALL <br />WOR3CERS COMPENSATION LAWS <br />IN11Yj 24 1101UR ADVANCE Nuno- QU4Ctlip b'OIt iNSYECTIUNS <br />SICn¢D <br />TJTLE 212 710 <br />DATs <br />Application Accepted By -- <br />Grout Inspection By <br />Pahp Inspection By <br />De truetion lospalion By <br />COMMENTS <br />Date 13r <br />0 t <br />Dote <br />Date <br />Date <br />Area PmployvoIDN _z (/ <br />❑ SPECIAL Well permit <br />O WAIvER Received <br />Caeutrucrcd Well oemb R <br />Jeno 43-U2-UUb ma" watcr tvoil rctmit.doc <br />812WZ003 <br />6 <br />V'j <br />N <br />�1 <br />