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drD� WELL DES"r JCTION PERMIT y PUBLIC WATER SYS"i'EM ❑� o SAN JOAQUIN COUNTI'FNVIRQNAIENTAL I IEALTII DEPARL'NIENT 304 E WEBER AVE 3""FLOOR-STOCKTON CA 95202 - (209)468-3420 - I NON-RE171JNDAZILE PERMIT E CALL(209)953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED 1�1 JOUAauxE,Ss -A (4-f-I`li:-/ CETY'/ZIP✓��c�c�(( , iy`� O%%NER -...ad's /�i 4'�C[. / PITON F.��U`T��1" kf v OWNERAuuRESS S � N - CIrVISTATOZIP M ' J 111 L)L 1y CON-fNACIi)x AppRESS L�14 j /� '7-} �1,� CIl'Y'ISTAi'E1Z tP 1l1-- Y C-57 lY'ELL DRILLING LICENSE NUM1iBEK� -/ 1 s/l� - EXPIRATION DATE PEREORA ION CONI RAC 1'Ox PHONE PE:RPf7RA'l'lllN CONTRA(:TUR AimuKSs CI'l'1'1STATE:/ZI 'UP P C-57 Well Drilling License Number Expiration Date ❑ Bureau ol'Alcnhnl,Tobacco:rod Iirearots-Users of Ellgh lixpinsi vcs License Number Expiration Date ❑ CIIP IIazardous Material Trausponalion lur Px pinsi ves License Number Expiration Date ❑ San Joaquin Courtly Shcrill=Coroner F,xplosives Application and Permit License Number Expiration Date ❑ Caii}bniia Occupational Solely Ilealth-Blaster License Number Expiration Date RE.A,SON POR Dv.sI RtlCMON A Dry ❑ Replacement Well b Caved In ❑ Pit Well ❑ Inactive ❑ Test 11010 Detected/Suspected Well Water Contaminant(s): , Adjacent properly with contamination(Address): Known Soil/Watcreunlanrioants of adjaccnlpruperty: FRIM ING WELL CON.SFRUCTION DrA'ALI,S,-Hl:.Opcn Bottom ❑-Gravel Pack ❑ Uncascd ❑ Other Well Log copy attached 13 Yes RL No Groul Seal ❑ No ❑ Yes ft below ground surface(bgs) Hole Diameter inches J Well Conductor Casing ❑ Yes FaL No Depth of Conductor Casing it bgs Diameter of Cunduetor Casing _ inches c�Y f1 Well Casing Diameter J inches Tolnl Dept it S�_It Depth to Water {�11 Depth orCasinn - bgs (�1' N DESI"R(JCTION SPECIFICATION 1 Scaling i57alerial linin / —ft hgs toR bgs Filler Material liom IS hgs to ft bgs ryt, Well casing to be perforated by one of the following methods - from Ilbgs 10 ❑ Mills Knife Number orcuts every fl and/or ❑ Explosives ❑ Detonatingcord: ❑ with projectiles every ft ❑ witholitprojectile C� ❑ Detonating cord and boosters: ❑ with projectiles every ii ❑ without projectile C ❑ Other Scaling Material ❑ Ncat Cement(94 fh hug/S-fi gu!xalx•r) ❑ Sand Cement suck coir/7 gal water 2�Bentonile Pellets IRI:Jientooitc f211%".1ids) ❑ M an a lhcturer Spec%snliils_ _% N:vnc_ ❑ Specsortf711C ❑ Specs Submitled 1 Pht—weal Methal ❑ i'uu 1-1 Fret:Pall 13 1 nhcl_ .tied C.n.14,11 ; 11R' f'om delc wish f(i u.hrunm('o r '�'7. - - Il h•.cs ❑ l'ungrlcl a i:xLsElug Su rTacc Pod 11 1 III•;REBY CERT-11'Y THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL RE DONF 1N ACCORDANCE WITH SAN JOA'QUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS, 1 ALSO CERTIFY THAT MY REQUIRED LICENSE 1S CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL WORKERS COMPF,NSATION LAWS. MINIMUM 24 HOUR ADVANCE:NOTICE REQUIRE;[)FOR INSPECTIONS /r,�... TITLE:�:f &1-"-L DATEII'I'y CONTRACTORSSICNATURE: �L P A� i P,,\Ymol.l T �Y Nov 2 . 605 Y. � I � SA ENO RONME�ALTM . - ARTM�Nf I DEPARTMENT USE ONLY npplicatino Accepted By �`L.`` Date /I G.r Arca Destruction Inspection I3y—:P•}'" Dale 1t Employee ID# J / COMMENTS PE SC keccivcd Che Amo(lnt bete Permit! Invoice# Well IDN Codes Info Is Cash Rentlited Service Request# 7-4 1;11D 41.0.'M welt ncso-uriion PC iT Addendum 4604 is 6.9.04 a64