|
WELL/PUMP PERMIT
<br /> ` .}SAN JOAQUIN COUNTY F,NVIRONMF,NTA. -JIU DEPARTMENT 600 1iAS7'MA)N h._--I-STOCICrON CA 9.4202-(209)46834211
<br /> NON-REFUNDABLE�PEERN1rr 1•IAC C��A/�LL 209! 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED
<br /> JoanoDREss �G,,,ySJS,�-WES�_- yy_!-4�S"C�~yA 1 NCi'ry/7 P_
<br /> - LA
<br /> CROSSS'rREE'l ',1( APN 12�J 9031 _ PARCELSIZE _ a
<br /> OWNER NAMF, PROrN� }___-_.�.--_�.
<br /> OWNER ADDRESS C 0.p60 X 97 CIIY/STA'rE/ZIP HoL 1
<br /> CONTRACTOR
<br /> 7481+1\. 44NSU�TAMTS PNDNE - 2�_-. "
<br /> CONTRACrORADDRESS 3911 W GAPITAI�AVE- ._---. CITY/STATE/ZIP WEST SACRAM&NTD 9a6l?l ,
<br /> StwomrRAC-rOR _,-„_- �_ _-_ PII<)NE,.,,__-._,-,____•_.,__ _._.__-.__
<br /> SUBCONTRACTOR ADDRESS_,. ,_,,,_„_„•,_,"_,,,_-_-_,-,.- CITLY//STA�T7E/%J --_-,
<br /> P ..- --- .....
<br /> _ . .....-._ .___,..„_
<br /> LicENsE C-57 0 C:-61 ❑D-09 [30th,,,.--- NUMDER_,.�6.6 /"-D EXPIRA'nON DATF'.
<br /> GEOGRAPHIC'AI.INFORMATION: Coordinates X=JR,_5.7_'i5??._0 Y-.3..71R&S.gg&.0 1'n.rnship._._-_.. Range__,_ Section_.-_-,____
<br /> INTENDED USE 0 Domestic/Private 0 Irti6ntioniAgricuhural ❑Industrial 0 Water Quality Monitoring Soil Sampling/Characterization
<br /> ❑Public Watersyystem _ __ I-.-H-IN�_. -H 915L-34- 9—,� 7
<br /> If diMma ftom 0'nW':, �SI'atcr S}skm X, ----� Contact Nnnx•or Phony Nnmtkr
<br /> 'rYPEOFWORK )(New Well 0 Replacement Well 0Well Ahemtion/Madification ❑'rest Hole ❑Other—__
<br /> XMonitoring
<br /> ther_ -
<br /> XMonitoring Well(s) numtxro(xans O Soil Borings)_— nnn,nerufMviok A Geotechnical_'____. ^'nnh,r„rt~......
<br /> ❑Well Destruction ❑Out-01?Service Well ❑(hu-Of-Service Well Renewal `A'-
<br /> ❑Ncw Pum 0 Pum Replacement 0 Pum Repair ❑('roes-Comtection Repair (V4i V41 C.OilvA{'{ thiL 9e0+eC�V)I CA
<br /> WELLCONSTRUCIto\ W¢1 -into A hl Morro Viel1 oftet
<br /> DrillingMethod ❑Mud Rota 0 Air Rota Au er 0 Cable Tool ❑Push Point 0 Othcr tL
<br /> Rotary Rotary �l , '�-- � �f-thinr�
<br /> Proposed Well Depth_ 60 - D Excavation �•L! in diameter ❑Open Bottom ❑Gravel Pack'Gravel Size_ in diameter O
<br /> 0 Conductors Casing__ in(bameter i Conductor Casing Depth-,..�_ .•,,.. ft S&--t I-,
<br /> Well Casing Diamcler—Z.—in 'rhicknessiGauge/ASTM Sched ❑Steel gPlasiie 0 Stainless Steel 0 Other
<br /> Grout Seal Depill - ft X Neat Cement(94/b bag/5-10gal uateri $([Sand Cement ,_sack mix/7 gal water
<br /> 14 Benumile(200%solids) 0 Manufacturer Spec°it)solids—% Name 0 Specs on Pile O Speca Submitted
<br /> Grout Placement Method g1lumped Free l:dl 13 Other __ ❑Retardant/Accelerator(ulnae)
<br /> PEDESTAL Installed By XDriller 0 Pump Contractor r 0 Other_..•.
<br /> 0 Concrete Pedestal Dimensions: Width Il L.cngth,_---1i 'thickin ❑Christy Dox 0 Stove Pipe
<br /> PUMP 0 Submersible 0 Turbine 0 Other _ HP Pump Set R Standing Water Level Il
<br /> W'F1I:).DESTRt1CnoN 0 Open Bottom 0('travel Pack 0 Unease(] 0 Other- _
<br /> Well Diameter._.....__._...in Tows DepthR Depth to Water__.....-......_.,it ❑Casing to he Perrorated from-,—it to It
<br /> Sealing Material 0 Neat Cement(94/b bog:'5-/0gol natter) 0 Sand CcuwntT_ _.sack mix r 7 gal water 0 Bentonite Pellets
<br /> 0 Bentonite(20%solids) 0 Manufacturer Spec'?solid,,".._............% NameO Specs on Pile 0 Specs Subntiuc(I
<br /> Placement Method ❑Pumped 0 free Pall ❑011ter-,-._
<br /> 0 Complete with Mushroom Cap ___11 Il bclmc grade ❑(_n;"picte n Isi tins,ti_r t,t c Pad
<br /> I ITEREBY CERTIFY'IIIA'I`I HAVE; PREPARED-11115 A11111,ICAIION AN 1)TI LT'I III: ))ORK \N 11,1. BF. I)O\1•: IN :YCCOItDANCE WITH SAN
<br /> JOAQUIN COUNTY ORDINANCES,STATE LAWS, A\1) RI I,I:S \\I1 RI<(ail.:\llfl\5. I \I.SO CI'RI IIS 111.\I �l Y 10:01 LK ENSE IS
<br /> CURRENT AND ,ACTIVE WITH TITE CALIFORNIA CO\IVa (-I(IRS AI:Y1h: I,I(.IUIL Ito %R1) AND IILCI' I :UI IN CONI1'1.IAM I'. If If ALJ,
<br /> WORKERS COMPENSATION L;YIY'S.
<br /> MI's I\I I'M 24 HOUR AWS kNCE;N0110E REQUIRED FOR INSPF.CT.TONS
<br /> SICNEI)r• ----.....--._-... . _ 7 rn,E__.Pilo et,-i t V 2$ 20 0
<br /> a'3 2007
<br /> HENT HEALTH
<br /> /SEMVICES
<br /> DEPARTMENT USE qNJ Y
<br /> Application Accepted By- L lb�c Area -. _ Lmpinpec int _. . -.
<br /> Grout Inspection By_ ..... - ._.._ Dau _ y
<br /> _1 SA O L__- ❑ 51'Ic(l'\I Well Permit
<br /> Pump Inspection By—. Late._....._.--_--.......
<br /> ---..-_- ❑ \'�I�ICRItcccivcd
<br /> Destruction Inspection By—_.�_T _.---- Dote___-_ Cnnsl ru wd k\ell Depil,
<br /> COMMENTS
<br /> _� �.— -_----- _.._._.._._--___._ .__•__-._--_---
<br /> PE SC Received (.'heck#/ Amount Permit/Codes [art) B Cash Remitted Date Service Request# Mvnice N Weil]I*
<br /> ZIC I 1105-2,-
<br /> 0111)
<br /> o vSLID 43-02-006 WED Welt Pemtio and Gkdarodon.doc
<br /> 911 112007
<br />
|