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INTENDED USE TtnessizTritatz U Inismion Agricultural 0 industrial <br />Pichli, Mier S7stat <br />diffanz firm Was, Syvtgrts <br />CI Other <br />it CI Casing to be Perforatai lions Ft ut <br /> cock adz;?gal water U Bentonite Pellets <br />S'F'S on Fitz CI SpersSabinirmil <br />WELL DESTRUC2115 Open Banc= 0 Gravel Pack <br />Prow Dnamitsle Fartine 0 Other H? <br />0 Cocos:id <br /> <br />Weil Dimmer in Totai Depth ft Depth to Water <br />Scaling Material 0 Neat Cement i9411; bag 54( go! water) 0 Sand Cvm.nt <br />SIGNED <br />0 Complete as Existing Surface Pad <br />HEREBY CERTIFY THAT / HAVE PREPARED THIS APPLICATION AND THA.T THE WORK WILL BE DONE IN ACCORDANCE WITH SAs <br />bOAQUEti COUNTY ORDINANCES.. STATE LAWS. AND RULES AND REGULATIONS. / ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CCHRENT AND ACTIVE WIT THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORICERS C I • ' ••;-•'!. <br />Tg <br />/ptiziep <br />DAM <br />Amount <br />Remitted cy- <br />+77 JO )L7 g <br />WELL I PUMP PERMIT <br />SAN JOWL IN COUNTY ENVIRONMENTAL DE ALI El DEPARTMENT <br />NON-REFUNDABLE PERMIT <br />600 E Am,. STREET. STOCk-CON CA 9'3202 - (209) 46E-3420 <br />EXPIRES I YEAR FROM DATE IsseEn <br />7'. ADD.. _____17:/if/;(5 GP unizi, S7ec--42D/V _5._._/ 0 <br />Cons S nun `-477-rw--__C/4177- 62) "PM fr - A„ 0q60S- i ,a P.,-Fr.sur, 1. S 1 <br />OWNER NAME 4 17/11-1 Al/Mvvc/C <br />ot,E.A.Lss _1444 C anis-L.-0z,, <br />CON TRACTOR 4-,6,6 a)/i-re-2z_ It4?-7Z -- <br />CONTRACTOR ADDRESS /6 /70 S /741/y 2 c,..,...,„,,, <br />SUBCONTRACTOR _ PUONE <br />SUBCONTILACTOR ADDRESS <br />1.10ENSE 0 C-57 KE-6I D.09 0 Other Nt 4131.11 Z1.7,4h4 EXPIRATION DATE ://3/ /2 7 <br />GEOGRAPHICAL IN:FORMA DON: COOMIIRStes X 'township Range Sechen <br />Li Monitoring Well(s) <br />0 Well Destruction 0 Out-Of-Sim-ice Wel; <br />0 New Pinny imp Replacement 0 Porno !Izmir <br />WELL CoNsTaLcHcpi <br />Drsilhag Method Mud Rotary C Air Roary 0 Auger 0 Cable Tool CI Push Point 0 Other <br />Proposed Well -:/eptts ft Excavation in diarneux 0 Open Bottom <br />0 Conductor Casing in diameter I Conductor Casing Depth <br />NVell Casing Diameter in Illickness'CmuyeASTNI Scheel 0 Sleet <br />Grout Seal Depth (t 0 Neat Cement tYx it'. tag: S-10 gal :inter5 <br />ra Be Ito /20'. ',.3 solids) 0 Mainuleentrar Spec "; solids <br />Grout Placement Method 0 Pumped Cl Froe Fail C.,....4Wee- CI Retardant : Accelerator (name) <br />5al- <br />;izzey .s//A65 <br />OI NiSTAtriZle <br />TAPE OF WOJ W Weil UReplacement Well 0 Welt Alteration:Medificnion CI Test Hole <br />nu,s,,ei u:as soil Bprin.4s) r-ella:r•4 basing, <br />CI Other <br />Ocotcchnical <br />Cita-Or-Scrsice Well Renewal <br />0 Cress-Conamlicara Repair <br />1-..cab,•,11,31.7i1V. • <br />0 Gravel Pack , Gt2Yei Size in diameter <br />ft <br />CI Plastic 0 Stainless Steel CI Other <br />CI Sand Cart= sack rair 7 gat water <br />Name U Spixs on File C Specs Sulanitt. • <br />PEDESTAL ;est:tiled Bv rti" ;Contractor <br />0 Concrete Pedestal Dime, Width Leneth <br />0 Bentonite (20% solids) 0 Manufacturer Spec solids '`.; Name <br />Meatiest Method 0 Pumped 0 Free Fall 0 Other <br />0 Complete mmnt Mushroom Cap ft below grade <br />Application hemmed By <br />GUMS In on By <br /> <br />Pomp Invention By <br />Destruction In wetter: By <br />COMMENTS ii)Y1 en f Inco ton is-rvo II - <br />CkkiI1 Employee IDe 14.5 <br />Date 0 SPECIAL Well ftoolt <br />Dare 0/21_ 0 WAIVER Received <br />Date Constructed Well Depth ir <br />DEPARTMENT L S ONLY <br />Due <br /> 1 It13111 <br />Welt rtn-.;,, e4r9 De.r.laraz.'r,7 <br />Received Date Permit/ <br />ittemat <br />SC <br />Info <br />PE <br />Codes <br />0 s' 0 <br />/awoke N Well IDE <br />RHO 43,02-006 %TB <br />9, 1 I , 2097 <br />0 Waw Quality Monitoring 0 Soil Ssurating-Chioncteriv anon <br />0 Other <br />. Thick in 0 Christy Box 0 Stow <br />PurtAl SV2___11 Standing Water Le, el 712 ti