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JUnJUN. 7. 20071 9:41AM WxHham slowik 55se3B . 655 N0. 1120 P. 'IF•t <br /> STANISLAUS COUNTY DEPARTMENT OF ENVIRONMENTAL RESOURCES <br /> 3800 CORNUCOPIA WAY, SUITE C. MODESTO, CA 855358 <br /> (209) 525-8700 <br /> Application For Monitoring Well Construction Permit <br /> (This Permit F� Year From Date Lnuem <br /> ApplieaHoa b hereby made to the Stacnt+ut Cemty Department of Eavimnwombd Reso for a permit to conduct the work <br /> htirSa datrlhe6 Pkare notify the tfaaardonr[dateriala DWbku at least 48 tioan ht advanmef starring thewmrk. <br /> FACIIIT''E/SM NAME <br /> JOB ADDRESS/LOC +� e F x" ✓ dro : ' , <br /> CrrY/STATFPL[P vP S A C3 i c n . Qh1 O -'Oe'Z-6 W 3 � 1< cFW <br /> OWNEbt'SNAME a e rev ^( °�. ADDRESS "�LenrPi Cry 1oaRz ��r <br /> CTIY/STATFJLIP ��� cA 593 PITONS zr} r:V-3 5,Arc'141 14 ur) 4-j <br /> DPXJMGCONTRACTOR } ; r G C-57LICENSENO 2. 3' u - <br /> WORKMAN'S COMP if .Peen OCE. r+ o, 'fid 6 <br /> CONTRACTOR KIONE � - <br /> I[ppmm+raanofthewell(s)wiYfoNom,rneihodnbgf �mTimiort:plaleomfaetdWWo o[Tmrito�N+lResaaoes, <br /> pl�• :hctiikA�movvwtic � amddau Gb 1 i1cc,l7YrATin� <br /> u �2' <br /> T YPE OF WORK{ !? SY L{Chtx]t): <br /> n install New Weil GrOuK waterMoriitoti wdsu njift <br /> NumberaifpNewWells [ 0 Grw�odw4wF-ttadion <br /> )sr bwa NwAber of T�Well(VL <br /> ) 0 Otteoid Tojection _ <br /> E) Other <br /> ❑ WelL Desttuetiion <br /> Number of Welts ToDestro �� UMTHOi)OF DRELLIKG(Check): <br /> a Otho Iilfsutoation S - r �`) q- ❑ Hollow Stem Aul�i. <br /> ar <br /> Du S$w33 X other ere " -4WToO- <br /> CONSTRUCTIiON ICAITONS: DWrAXCR TO NEAREST: e <br /> Bonng Dkmder Domestic Supplep Wil 2t2-50 _ r <br /> Ce>m+8 T DlTO Gtatmdamew.and Gauge SeLines or Septa TanFti made Feld <br /> Expected Depth o£Well- wy 2 _ wer <br /> Rock Well <br /> or F Sh Dri e 7 rte_ <br /> Depth o£Saecnat intervalOther <br /> DepthofFhaPa* N DESTBUCrIOP1 OI?W1,II: <br /> Size of F11w Pack M�aial <br /> mid Slot siu? 1111r Well Diameter <br /> Depth and Type of Transitional Seat Well Depth <br /> Depth and IyPt ofCmaSeal at,e 6etttedl deuptran mataialAoimnemdptooedorsm <br /> Q�erl+tgS e >(j .6e- Ab Cel tt5� <br /> 8�•r^ d- 'j'reP ie s 'e <br /> NOTE: A dwiled and waled site plan with proposed drtTlitig loca6nns.214 proposed well e'*U ructiou <br /> disgmus~s MOST be attached tO this apphcaticu. <br /> IMWBYCERTIFYTHATIHAVEPREPAREDTHISAPPLICAMONANDTHATTHEWOFXV LLBEDONEIN <br /> ACCORDANCE WLTH TM pROVMONS OF THE LAWS OF THE STATS OF CALIFORNIA,TM ORDIIJAd M OF TM <br /> COUNTY OF STAND"US.ANDTHE RJ-JM A +iD RBaElLATIONS OF'11E STAMAU. COUNSYUFBARTWENT OF <br /> EDiVlit 1 �(5���(v3fi�?tgS <br /> SiCrhlE17 Date: OL <br /> owner or Authorized reseotative <br /> Permit bsted By: ❑ Permit Deirkd By: <br /> PERWr IV[JrdEBEEL Dau.: <br /> DATE ISSUED: <br /> Iorpected By: IF? Paid: Yes!_No Amount .Q <br /> Date. fiT <br /> 4013-58 ll <br />, <br />