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6HO'ON NW:ll 9M '86'130 IWIJ paAI;3;� <br />WELL DESTRUCTION PERMIT ', , f:'C- �-10 <br />. 1400A &44 11%1/11, 4&• PUSS WATER SYS7M ❑ Yes ❑ No <br />SAN JOAgWN CouwTY ENinnoNMENTAL HEALTH DEPr 1868 East Hazelton Avenue-STOCKTON CA 9520-18232 - (209) 41683820 <br />NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FRom DATE ISSUED <br />JOB ADDRESS o s s i e r RD crrrm.E <br />cRoss sntm Enterprise RD APN f 0 PARCELS <br />OW.YERSJC Public Works Dept PHONE <br />OMER ADDRESS 1810 E Hazelton Ave Ctrr1STA7JMPst o t <br />scalon95z-ju <br />91E LAND UsE APPucATwN N <br />CONTRACTOR ADDRESS G . V . u v� V -t <br />QTYlST <br />—F <br />C-67 WELL DRILLING UaN3E NUMBER 377923 <br />FPPxjpAtRATION TE <br />R <br />-f- 3 1 "' <br />PERFORATION CONTR1lCTOR_ /Y�� <br />PHONE <br />PERFORATION CONTRACTOR ADDRESS . ��i <br />CnYISTATFJLP <br />❑ C-67 Well Oriing <br />License Number <br />Ex"llon Date <br />Bureau oFAlconol, Tobacco and Firearms - Users of High Explosives <br />Ucense Number <br />Expiration Date <br />CHP Hazardous Material Transportation for Explosives <br />License Number <br />Expiration Date <br />San Joaquin County Snerift-Coroner Explosives Application arta Permit <br />Ucense Number <br />Expiration Date <br />Carfe.mW Occupational Safely Health - Blaster <br />Ucense Number <br />Expiration Dare <br />REAsoNFo!LDEsTRucnoN ■ Dry ❑ Replacement Well Q Caved In ❑ Pit Well <br />❑ Inactive ❑ Test Hole <br />Detected f Suspected Well Water Contaminanl(s) <br />Adjacent properly with contamination (Address) <br />SA <br />Known Soil I Water contaminants at adjacent property <br />r -l( <br />EMTING WELL CONITR'IJ-5—MN DETAILS ❑ Open BM3,tn ❑ Gavel PW -k ❑ Uncasec 0 Other -'7 ti 1 <br />Wei Log copy atlac led ❑ Yes ■ Nb Grout Seal ■ No ❑ Yes R beow gral.nd surface (bgs) HoleDlareeter inches <br />Well Conductor Casing ❑ Yes ❑ No Depth of Conductor Casing h bgs Dlameterof Conductor Casing V_ inches <br />Well Caahv 0lametar_7--roars Total Depth _� P ft Depth to Water -6' It Depth or Casing adtW R bgs <br />Seating Material from _10't bgs to7� n bgs Flser Material ,�L�A.- rmm R bgs to ft bgs <br />Well casing to be perforated by one of the following methods! from It bgs toR bgs <br />❑ Mills Knife Number of cuts every R end / or <br />❑ Explosives ❑ Decorating rsrd ❑ with projectiles every it ❑ without projectile <br />❑ Detonating cord and boosters ❑ vAth pmj&ci*s every !_ it ❑ without projectile <br />❑ Other_ <br />Sealing Material Neat Cement (94 fb bag 15-6 gal watery Sand Cement io. 3 sack rnx 1 7 gal water Bentoni s Pellets <br />Bentonlle (20% solids) Manufacturer Spec % solids % Name Specs on His Specs Sutrrined it <br />Placement Method PumpedFree Fail O!ter <br />Seal Completion Complete with Mushroom Cap 3 n bgs Comolete le Existing Surface Pad <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORM WILL BE DONE IN ACCORDANCE WIT" JAN <br />JOAQUIN 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 1 AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />r <br />73' <br />Application Accepted <br />Destruction Inspection By <br />COMMENTS <br />CE NOTICE REQUIRED FOR <br />_EAEPARTMENT USE ONLY <br />Date Its <br />En <br />a <br />r <br />e <br />, ;0' NTjr <br />R CEIVE <br />T 2 Zoe <br />Ann *I `R <br />Employee 00 W0 s <br />EMG 4306 <br />I&YO7 <br />i7D <br />WELL DESTRUCTION PERMIT <br />HEk <br />