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LMATIQN NOT CHECKED <br /> ORIa1NgL WATER WELL DMLERS REPORT Do Not Fill In <br /> File Original,Duplicate and Triplicate wnh the (seett0.9 7076 7077,royg,W&ter Cede) N° 34959 <br /> REGIONAL WATER POLLUTION <br /> STATE OF CALIFORNIA _ _ <br /> CONTROL BOARD No / State Well N0 <br /> �;errrs.ppraprlalr ssrbn) / 7 w er ` i <br /> Other Well 730.__I tx <br /> OWNER: (11) WELL LOG• <br /> ame LOlIJ S A fe? z cave Total depth Irj8 it Depth of completed well 166 IT <br /> Address Rt 1, Dox 80 Form stioa Drtrrrbr by talar rbarrrl.r,s.rr of marerlel .cad strrrlstre <br /> Lat-rop. California C ft to 36 it sand <br /> 40 S-nd & c:ia-- <br /> (2) LOCATION OF WELL 40 48 Sane, x r,.vf l <br /> County .S'an Jo _,.in Owner s auatber Lf any— X_ ROCKS �C Sd71d <br /> R F D or Street No 52 T ­h Cil <br /> D 72 it r <br /> so Gf-►=� R <br /> r <br /> 92 104 <br /> (3) TYPE OF WORK (check)- <br /> New tired Deepening 0 Reeondiuomng 0 Abandon <br /> If aband"ment,describe rnaterwl end procedure in Urrn 71 , -r <br /> (4) PROPOSED USE (check) (5) EQUIPMENT - <br /> SP nd. <br /> Domestic F-1Industrial ❑ Municipal E] Rotary ❑ r r <br /> Irrigation r) Test Well ❑ Other ❑ Cable <br /> 53 a- <br /> DugWell ❑ <br /> (6) CASING INSTALLED If gravel packed C <br /> SINGLE© DOUBLE L7 Gage <br /> FIOm or Diameter from to <br /> ft to ft Dram Wall of Bore it it <br /> Type and.,ze of-hoe or well ring l R S-ze of gravel <br /> Deser.be losat <br /> (7) PERFORATIONS: <br /> Type of perforato-wed <br /> Size of Perforatto.. in,lenitth by in <br /> From n ft rn FtA ft Pert per row Row.per ft. <br /> (8) CONSTRUCTION <br /> Wu s surface unitary teal provided? ❑ Yes ❑ No To what depth it <br /> Vert say strait sealed agwnst pollution? ❑ Yes 0 No If yes nate depth of strata <br /> Frons —r t <br /> fr to <br /> It <br /> lit <br /> Method of Sealing Work started ,2-21 a 55 Completed r 5 <br /> _ 3-2- <br /> 1! <br /> (9) WATER LEVELS: WELL DRILLER'S STATEMENT <br /> r r� <br /> Dapt>t at whtth water was first found 1 ft Thu Wdl juar drflle�xrrder M;ia raldsetson and ibis reporf ss trxe to for best of <br /> 16 MY Enowleirge red ww <br /> Ing leve]before pvfontrag ft <br /> NAME `OCs rl7N ,9 ' ,arnr.+ue <br /> lax Leval after performung <br /> ft {Perron Srm car eorpont,onl lry?+rd or yrrrrrdl� <br /> Address 646 SouLh Calif oz nia <br /> WELL TESTS. <br /> ~uaPump rest mase? Stockton, California <br /> ❑ Yes ❑ No If ran.by whom? <br /> Y41it gal/ante with It drew down&fur hn [SIGNED] <br /> 67850 �l#� <br /> r9bePar&tt-re e(cancer r'.r a e.hem,ul&aely.rs m►de? ❑ Yn ❑ No License No, Dated <br /> _ _ -- <br /> -- ---.— —..._..-__.— <br /> 0'ae olntrtc log made of well? [] Yn ❑ No 989.9 3 9a caw bin 0■rb DWt4 IeORat NO 246 i"10 S 1341 <br />