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WELL / PUMP PERMIT V <br />/ 1 S.1.XdOAQW.NCOUNTY EsvtRo%wtEATALA£ALTHDEP.tRTm,,T 690E.anNIAINSTRErr-SrOCKTO'iCA 95202-(2 468-3420 <br />;VON -REFUNDABLE PER.NUT� / ( EXPIRES <br />[�I. YEAR FRO -M DATE ISSUED <br />•JOB ADD}ti'�S��r� /I,�W-2 <br />/V I <br />CROSS,TRELT _;1Afe,0&142 <br />_ /� <br />—` L ---—wuv�V/ r /.`��[J�— v.o��. c..,.- �Y-1�v <br />OWNER NAM1IL' '"1z <br />OWNER ADDRE" ' <br />CO\TRVCTORADDRESS�a <br />SuBCOATRVCToll <br />SCNCORTR\CTOR ADDRESS <br />LicEnse LIC -57, -61 C3 D4)9 0 <br />GEOGP vaucAl. I%SORvitlto%: Coordinates X <br />0 <br />�`• v l`.'f�:_ �1 PDO. E <br />C111f%TATC12IP___` _ / <br />_ Nt?taER 1�7y�� E\PiR1TIM D.17E ____� <br />To%nsbiri Range _ Section <br />I�rEnpEn Use Domestic:Private 'Sation;Agricultural O industrial C W'aterQuatity Mo.titoring 0 Soit Sattrylipg:Cha*actcticalion <br />❑ Public Weer Systan .--- -- _ __ Ijf <br />li'dd:iR�lica:Q.nr _- N':rrr STti:.m ern:: l<i.�V-.w:. ..-Pi�ccs vveS:: <br />1YDEOFH0RR U New Wali 0 Replaerment Weil O Wcil AlteratimModificuion 0 Tex Hole C7 Other <br />0 Monitoring we1(s) �" +<•f P: ❑ Soil Borirt;tsl r'ammfr f trodne, ❑ Cmotmitt ical iK.,rtti.rieg: <br />oilCksmlction 13Walk0Ov1tOf-&m;cnWelt Reuev:31 <br />WELL CONWRU 1`101 <br />DrUllog Methad 0 Mud Raw, 0 Air Rosary 0 Auger t3 Cable Tod 0 Push Point G wwr__, <br />Proposed Weil Dcpth — ft Excavation in diameter <br />O Open Bottom M Gravel Park i Gravel Six in d--. <br />O Conductor Caning in diameter i Conductor Casing Depth ft <br />Well Casing Diameter—ict Thickrless'GaugerAST\t Schcd <br />C3 &M ❑ Plastic O Stainles, Steel 0 Oilier <br />Grout Seal Depth ft 0 Ncat Cemcct ; 9.t 16 bag.' 54ugal Avrerl <br />O Sand Cameo: _ wck miv, i 7 gal water <br />0 Bentonite r2U;esolidsl 0 blanufe-ntrtr Spee".'n solids °;, <br />Xan:c --T 0 Specs on Fila 0 S=sSubmitted <br />Groat Plneeraeat Nethed OPumped ❑ Frec Fall 0 Other <br />0 Retardant, Acraletator (name) <br />PEDESTAL inRalkd B4 ❑!Mil:r OPump Contractor <br />OOthcr_______._—_____� <br />❑ Concrete Pedestal—as, go%-Widill_, it Leaeth_ <br />Thick—in 0 Christy Boz D Since Ne <br />Pulls. submersible furbine ❑Ocher HP <br />PumpScl5gg:11 SundiagWater Lvci it <br />WELL DESTRCCTIO.N 0 Open &1forn O Gnivol Pack 0 L'ttcn.:d <br />0 Ckhzr <br />Welt Diametr_____ in Total Depth_ ti Dcpth to Water <br />_ ,_ fe 0 C mg to tm. Perforated from fi to it f <br />Sealing -Material 0 \cat Cement f94 1b bag. -70gni rarer/ 0 Sand CcmL nt <br />.rack mix; 7 gat water 0 &ntoraw Pellets <br />0 Brntmite 129'1;. solids) D Yfanufacturr Spec %solids •_, % <br />flame 0 Specs on File 0 Spec,,; SubmittedPlacement <br />Metiod 0 Pumped 0 Free Fall ❑ Other <br />0 COMP19'.- a ith 1,lushroum Cap ft below grad4 <br />0 Complete to Existini; S r&ce Pad <br />RECEIVED <br />MAY 2 4 2018 <br />)NNIENTAL HEAL" <br />IEPAUNIENT <br />Application Atxxp 0cl — V 4 Dae ���� tt v Area Employee ID# gV fes_ <br />Groutl/Lv7uxiionBy Date SPECIAL Web Permit <br />Primp laspatton By rj _ Date 0 WAIVERReeeived <br />Destruction Inc eetior. BY,_____-- -- Dail Constructed Well Depth -_ f< <br />PE S 1Rev~ Amosot Da Service Permill noon# invoice# Wen WN <br />CW011; Info41-4 ­5vo <br />SI <br />f <br />EHD 43-02-006 WEB q'eL Permir aral D:clarmv-.dw <br />9/11,2007 <br />■r�■r�rr■■r�■�rrr��■rrrrrira�r�rrrrrrr�■rr�rrrrr■� <br />. r <br />■rrrrrr■�rrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrr � ` r• <br />■�rrrtt�rrrrrrrrrrrrrrrrrr�rr��rr�r�rrrrrr : <br />■rrrrrrrrrrr�rrrrrrr�■■��rrrrrr#■rr�rrrrrrr <br />■rrrrrr�rrrrrrrrrrrrrrrrrrrrrrr�rrrrrrr <br />■rrrrrrrr■r_�rrrrrr�■rrrr■�■■�r�■r■i�rr�r�■�rr■trrr <br />���������� r.:.��i�r:.�-ii�:rra►.�rr�:tl�r � rr��a■■rrrrr <br />Application Atxxp 0cl — V 4 Dae ���� tt v Area Employee ID# gV fes_ <br />Groutl/Lv7uxiionBy Date SPECIAL Web Permit <br />Primp laspatton By rj _ Date 0 WAIVERReeeived <br />Destruction Inc eetior. BY,_____-- -- Dail Constructed Well Depth -_ f< <br />PE S 1Rev~ Amosot Da Service Permill noon# invoice# Wen WN <br />CW011; Info41-4 ­5vo <br />SI <br />f <br />EHD 43-02-006 WEB q'eL Permir aral D:clarmv-.dw <br />9/11,2007 <br />