|
FF�)
<br /> 1H1* SOP • • P.07
<br /> It 2
<br /> WELL DFS'I'RUCTION PERMIT
<br /> it
<br /> AUG 2 3 20C16
<br /> 1'17BLIMATER SAKI P.m r.]Y..(7N,.,
<br /> ENVIRONPvIIEW 3W E WEBER%Vfi J"'FR.-"I(H KION('%'35201-(10q)468-3420
<br /> PERMIT/SERVI - -"E'�L'NDABLZ PIE OMIT, ('Al 1.(2101 1153, 7(")'?I'mc IN'Wt< 41(0,14 EXPIRES I V F.Ak FXIINI DA I'v T.Wrj:p
<br /> ,1nB Ablill 0TV1.11. q5 3�
<br /> CRoss STREET APN
<br /> STU.. LAND IINFAI-01.14 AP KIN M
<br /> -T-, :
<br /> qciuWv"�s AU)Nv-
<br /> T
<br /> Owr4ER ADDRE&si !M ,,T,, TE,7, T�tisbalq'
<br /> CoN I KAR.-rox &.--q J�m Up t)f-J, 6 yx- oil I 9A.5 &/0
<br /> CIONIKA4411,411 0.533 &QS4-a0-(t'ttW*_1ITV/S1Aj'Pjzir
<br /> U C-57WELL DRILUNC LicmENUMBER —EXPIRATION JFIV
<br /> PFRF0kATIdN CUNI HAVICIR Clf'llu
<br /> X
<br /> PERFORATIOM CONTRACTORADDRTI.�.4 o2X6 alnLYlVePHONE-1_._C'ffy/nArE/ZFF
<br /> C'-17 Well su Number ifion Oma
<br /> 0 Buicau ul'Akc&l.TubAcco and rneams-1!.qer%ofIligh rxplmivea I. Number Fxpirawm I)AIL,
<br /> 0 CIIIP I laynirdnio f LiceriwNurrber Vale
<br /> 13 Stin kmlurii Ultiniv Slivridl-Curovei Lxplowyes Application and Permit Nqt�.. Expiration r)we
<br /> 0 California Occapaiinrint SAfevy He.flih-Hbwf:. Li"rim Number
<br /> I Well
<br /> Vln.,,,,it Tem I late
<br /> Xtglm VnK DILSFRUILM rV 0 Replacement Well ❑ favedin 0
<br /> Detmed I Suspected Well
<br /> v-P4,4Ylh cunlaatinaliun(Address)
<br /> adjacent prop"
<br /> FXISTTN(:WFI I rCjr,4'rjRl lip JAII% 11 (hvti EIVROwl (.]'(ravel Pack 0 Piteaw"i ❑ (Allu
<br /> Well Log copy attached Y C3 No Crotid Seal 13 M. n ycb it Wow wound surfwe(lhgs) Illoltilh.--l- inches
<br /> well Camiluti 4*.i..r.
<br /> N,- Depth , _ft bgq th--l- Casirl inches
<br /> Well 11immejer orches Total Depth_f! Depth In WAI Il Depth of Casing II bp
<br /> nF'.TffVfTjQEL%tU(lFit rAt fUN
<br /> SealingM.1-W 1- II bgs lu ftbgs Filler NJnttwiRlI__. win 11 bits ta ft h
<br /> Well casing in be peI-fqk.-qd by nee of the fral"ing.ur-(bods; !ruin fl ly6s to fl hg.
<br /> 13 Milk knife .......--N 1w,td vwxvvviy 11 and/ur
<br /> n I:ipIoiive3 0 Ntunatinxcwd E) wlhpirn*iil"P.rr.y II 0 wnhouqw.)jwilc
<br /> 13 011tim 0 13 11,polcoIC5 V'Cry —151 13 .;lh t
<br /> S#A;dl NlAitrl 0 J-Agul-,wrer) 0 Sued C'emend A ent,;7,1,1,tu 13 Dentanite Pell its
<br /> 0 Bentonile(20%solids) 13 Manufactuner.;pec 1;solids % N Specs mifile M
<br /> Placement Method 0 P 111h.1 13 F,,w hill ❑ ()the
<br /> mei;v, n Cknnpluit Aith.Mushirwan Cup 173 (ollip1m,to Uistildid Surface Pnd
<br /> I HEREBY CERTIFY THAI I HAVE: FRKPARFA) IIHIS'APPLICATION AND THAT THE WOkK Wit 1.HF. IIQNF;IN ACCORDANCE WITH;AN
<br /> J1.14111.1N COLINTY ORDINANCES,STATE LAWS,AND R111,FS AND TIP GI I A 11ONS, I ALSO CERTIFY THAT MY RF.Ot III"ILICYNSE 15
<br /> CURRENT AND ACTIVE WITH TJIF CALIFORNIA rOVI'MAVIII
<br /> IHS STATE 1ACENSE BOARD AND TII,%7 I AM IN COMPI IANC).WITII ALL
<br /> WORKERS CONIPENSA I ION LAWN.
<br /> Ok.It 100 %Nq.1.Noi It, F FOR JOV,
<br /> CONTILACTORSSIGNATtIRK ,.,_TREE "MQ(Algh—
<br /> V DA'rF
<br /> R EC'EIVED
<br /> AUG .2 9
<br /> SAN JOAQUIN COUNTY
<br /> ENVIRONMENTAL
<br /> HEALTH DEPARTMENT
<br /> NI V,N T CSE 0 V
<br /> (a Area
<br /> Destruction losPect-11Y Date 11a
<br /> Pli: RKe.ived A a at Date I Service Reque --T frivoice#
<br /> Codjts I life It"nill.1 ,.r-dal It Well I[IN
<br /> ��uo V:01661!G mq!Zooq I
<br /> wal%'.In.,',"i'
<br />
|