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WELLJMAP F EnMIT <br />§4q4wAm4vwv(womwilTAl.Firl1irwDEPARTWIff I:::;PEA4THAZELTANAVENUE-SroCKTatICAa62DS-(2004 420•2420 <br />Pilf5.i01.fiIfFU. S Utt9 CALL 20� Sy3-7457 FOR INSPECTIONS EXPIRE.5 9 YEAR FROM 67A.TE 155UF <br />J,W Crt'Y/itP <br />S.Fi9f3 STA&BT_,,, .6t_��'� .a lA�„_•��'�_APd� `��� 1X�PAIAGEL 151ZE��..LAND U;iS�E �� <br />UwretLs: <br />R NAME r�tv� �• pg�/x Pt� <br />14N� Ar Y .l:�L`- L.il <br />Owtvin A0rFtt °t .S XA -- -_ lCrrYJBTATF/ZIP (:�QjU_�— <br />CornlaAcrua v' ,`„_} °I;! IPA C 4.C -y' <br />CONIRACTOR A00AM .- ClTYJSTATEIZIP__, 9�_ <br />5URCONTRACT019. <br />A00RE.." <br />610EWA <br />PkclM <br />C.ITYISTATE/ZM <br />D-09 Othef _ R' _ NUMIIER1S2&_0() EXPIRATUDM DATE i -i <br />0444RAPKiCAL bW*RVATtpd: Cloordlnetee $.._.. _ Y_�,- Township -_.___ Range Section <br />— <br />g1,DumestidPdyste lrrigaftVAgricukural IndOW-5l Water Quality Monitoring Solt SamplinglCharaeterizltlion <br />N4ll*w'IIC l *M'i. SVV1; ` YaeirigjawT19rnq 7Aon-*cChTann R Ler <br />'f'i lOw wvm e*. .lew Well R4plerer;ient Well Well Aftor,3hoNFAor}Ifi"11on Ott**r <br />Monitodng :Well(si-- ti of wells Sail Er�dnrri(W.l - R of tx,rinvs -. Geotschnicai - sof bunnga <br />Out -Of -Service Well Out-Ol-aerricE'r'lcii RGnrvI31'Cr;..s-CrAinectlon Rafialr <br />i Dritl:n2 Method Mud Fko%ry C jef Rotary Auger Cable To -A Pueh Point Other <br />1 Prrapo%ed Weil6gp1h -?a �7 tt &Iaystion --- 4, in <Mmeter Open Bottom Gravel PeckiGravel.Size In diameter <br />�. Conductor Casing ._� j j-... fn diameter / Ccrducirr Cos ng rJopth `-s (2,It <br />Wrlll Caning Oometer .L_ in Thickraessrfsaugo/LASTM Schedl�_k,, b_Q- Steel "_J',,Plaslr StalNceSSteel Other <br />Cirreut Sesl G, :lh-/ U U t; NSat Cemen[ 19d !b bxg:5-1G,g 1 n'at ar) Sand Cement_Zj2_j_ sack, mfx17 gal water <br />benlonlie (20% solids) Other <br />Orout Placement MqthodV Pumped Free Fall Other Retardant I Accelerator (name) <br />PE 'sTaL Installed By Driller Pump Gonlrartor 00 ! <br />-- Concrete Pedestal Dimensions: Width R L engin ft Thick in Christy Box Stove Pipe <br />— <br />j PutAn w,,SuDntrsr5ible Turbine Ogler HP .1 Pump Set ft Standing Watar Level (t <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />.JOAOUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />NORKERS COMPENSATION LAWS. <br />MINIMUM H R A{{ii��11"!lfA.YPE NOTICE REQUIRED FOR AINSPECTIONS- PLEASE CALL (209) 953-7897 <br />SrrSMEO '�✓_,�,G� i _..._____ TITLE.!!y.�l_(!f'_ CGIn-uC /O� DATE <br />^° f <br />o *rec rd <br />1`15 _- &Z� - X1111715 OI� <br />0!t <br />tK <br />11a 5 <br />� d yam; - Su.T�ux: <br />2P) - sfbve <br />2� Ser 757, <br />Ask <br />DEPARTMENT USE ONLY <br />Ap kvt Aa sr✓tgdh _ _ Dew u l i Are, U� ��%--- Employee IDY f <br />Giloa tnrpa 1st. _ Dale . l� /`/ L' SPECIAL Well Permit <br />PU4%Inspgcticnt a . ' — Dwe� � _..— l WAIVER Received <br />Con,Wructed Well Depth It <br />OIME.NTiS <br />p I Sc Hece"rnd <br />' coo"�E I Ir'Ifo By <br />Cirecw <br />Cash <br />Amoun; <br />RemittedD-te <br />Permit/ <br />tnvcire i; L Well IDS' <br />Service R ue->>". E <br />