FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

DELL DESTRUCTION PERMIT PU fERSYSTFJA ❑Yes ONO SAN JoAouIN COUNTY ENVIRONMENTAL HEALm DEPARTMENT 600 E i SmeeT-STOcwhofl CA 85202-(2118)468-WO NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED m CITyZv Job ADDItE55 [� e CRMSME t/ 4:N C APN OI 'i TLA qa I�,�PMCE15�_LANO USE APPLICATION# I O p G/OT Jeff I)TCdrrinfat PHGNE L/Oa. / -Q?- -ai?'d OWNER AOORFSS ✓ J CmISTATE/Ily OMak�I V E. 6/8/ {G C �CONmACTOR �OYI PHONE 15'6a-906-/964 a-6 "i_-' 9od7 _a Z V G CONTRACTOR ADDrtF33 6 CmSTpTFlLJP S C-57WELLDMWNG LICENSENUMBER EXPIRATION D--A�1TE�y SI'_91-ao/4 'i2 N t PHONE�6P1 /D 6. PenFORnnoN DGNTItALTOR I r / T Z � a PERFORATION CONTIACTOR ADDRESS�,.JYID /J'icGtnn Cm/BTATEIZJv S F S,o�rnw i ` ' 8-31 dUIU s o [3 C-67 Well Dulling License Number B69y686 Expiration Date n rn 10 Expiration Data CArii� co Bureau of Almhol.Tobacco and Firearms-Users of High Eposives License Number Ep. I;/�� CHP Hazardous Material Trensportati0n for ExpExpiration Datelosives License Number E San Joaquin County Sheriff-Comer EplosnDs Application and Permit License Number Expiration Data California Occupational Safety Health-Blaster License Number Expiration Date REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well Inactive O Test Hole Detected/Suspected Well Water Contaminant's) Adjacent property with contamination(Address) Known Soil/Water contaminants at adjacent property //h it d Exlsrum WELL CONSTRUCTION Darr n ❑ Open Bodom ❑ Gravel Padc ❑ Uncased ❑ Other Well Log ropy attachetl ❑ Yes No Grout Seal ❑ No ❑ Yes ft below gmuntl sudace(bgs) Hole Diameter Inches Well conductor Casing❑ Yes ❑ No DepthOf Conductor Casing, _It bgs Diameter of comuctor Casing�_inctxea Well Casing Diameter__inrhes Total Depth/Fla ft Depth to Waterers fl Depth of Casing JRa ft bgs D � ON SPPCIPICATION !!ll � Sealing Material from bgs h,yam_ft bgs Filler Material fmm If bile to R logs Well casing to be perforated!by one f e followfn metho f i')7 /k -4� from /49 33 fl bgs to /Q/ ft bgs XMills Knife Numberofadsevery V/Uftand/or ❑ Explosives❑ Demoting mm ❑ wimprojectileseveryfl ❑ without projectile ❑ Detonating ochd and boosters ❑ withpmlecbles every fl ❑ without projectile ❑ M Sealing Material Neat Cement(94/b bag/5-5 get watep Sand Cement�o.3 sackmiX/7galwalsr Bentonita Pellets Bentonite(20%solids) Manufacturer Spec%solids_% Name Space on File Specs Submitted Placement Method Pumpetl FreefalV Omer Seat Completion Complete with Mushroom Cap J' It bgs Complete to Existing Surface Pad I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MINIMUM 24 OUR ADV A 1OTICE REQUIRED FOR INSPECTIONS p.AL CONTgACTORS SIGNATURE _r TrrTE /�/dl�I.��t��I-NATE��— .. GUE7l ,S9t'��1�00V M:% /17.1lIoCr t'0 y :/c S01% cf ROA Ra/ o%¢ctn7f /0 I-ad4ld 4y-,CCS. 4 10.3 );Aek SIvrry 6dt11 b,- %/prlMie� -/;- Y /e ' 76 S1?6S- /A./if- knife G-vi"ll -f11.M /vk' 4,9 /D QGS. 0' dift3✓'I S AC—S. C-1 c" /71 KSIv'bOM C-P ( �/(�� DEPARTMENT USE ONLY q Application Accepted By /r'/</I" e-t Date �et7 Q I Area 997 DesWrtOn Inspection By Dale Employee lDt'-7 COMMENTS PE SC Receivetl CheclW Amount Data Permft/ Invoke# Well IDN Codes Info B Cash RemiUed SON!.R oast# Ivrs a2SC> Z &L U 17;V7/071 EHD 4308 WELL DESmUCTION PERMIT 101SW