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May, 9, 2018 7:11AM Canepa & ',ons No, 1418 P. 2 wtLL DESTRUCTION PERMIT PUBLIC WATER SYSTEM E]Yes E)No SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1060 East Hazellon Avenue - 9TOCKTON CA 95205-6292 • (209) 4663420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FDR INspECTloNs EXPIRES 1 YEAR FROM DATE ISSUED Joe ADDRESS /0,7.10 Ctrr/ZtP 9 rz zo i rrff 1 A CROSS STREET N�yrlv�Ny1 PN f00 y1 PARCEL SIZE� LAND USD APPLICATION it //' �?p OWNER �1/0M (/ PHONE 4.-- i V OWNERAODREaa/+�ww� �� 4k/J . fvE Qt -(r 4 LgAI Q�. CITY/STATFJZIP /.-,.w! CONTRACTOR �TN E�jry.V S lAffPHON01 v , 1- CONtRACTOR ADDRESS r~° �r i •Sv,vo �( Cm)sTATEIZIP h- �A-r1�,370 C-57 WELL DRILLING LICENSE NUMBER ,7S' 7y —EXPIRATION DATE P % 1- PERFORATION CONTRACTOR tftM jIwEZ.L+SEF-I M PHONE (91 - --,724 PERFORATION CONTRACTOR ADDRESSAf A Y4CITYISTATEIZtg*�F' 3 Z ❑ C-57 Well Drilling License NumberEXPlretion Oale -7 �a i Bureau of Alcohol. Tobacco and Firearms - Users of High Explosives License Number ON IF 11,,0 Expiration Dale 1� I San Hazardous Material T -Coro er Ex for Expvee osivesApplication License Number Expiration Dale San Joaquin County Sheriff -Coroner Explosives Applicallon end Permit License Number E><plrelion Dale Cahfornia Occupational Safety Health - Blaster Licen a Number Explral,or, Date REAaON POR DESTRUCTION ❑ Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well Inactive I] Tent HDIa i Detected 1 Suspected Well Water CDnWminanl(s) Adjacent Property with contamination (Address) i Known Soil I Water contaminants al adjacent property_ i E IaTING 146TRUCIION DETAIL3 ❑ Opan Bottom ❑ Gravel Pack ❑ UOCased ❑ Other Wall Log copy attached ❑ Yas No Grout Seal ❑ No C] Yes _ ft below ground surface (bgs) Hofe Dlemalar Inches Well Conductor Casing ❑ Yee ❑ No Depth Of Conductor Cas Ing 4 bgs Dismotor of Conductor Casing Inches i Well Casing D1amglerr) Inches Total OeDlh _2ft ft Depth to Wafer M1 Da th of e p asln0It bgs r Sealing Materiel from Q ft Dga to fl Dge Filler Material from R bgs to R Dga Wall caring t0 be perforated by ane Of the following malho from ft bgs to it bgs ' ❑ Mille Knife Number of cuts every ft and / or AL Exploslvae ❑ Detonating cord ❑ with pro)ecllles every ft ❑ without projectile I Detonating cord and boosters ❑ with projectiles eery H ❑ without prajoctte ❑ Other SaellntlMalerlaf NagtCement (B4lboeg/5-8ge)wafer) SandCament 1n•13 eeckmixl7galweler BentonllePallets Bonlonlle 120% solids) Menufeclurer Spec % solids % Name Specs on File Specs Submitted a Placement Method um Free Fall Other Seal Completion Complete with Mushroom Ca ry l D P p bus Complete to Existing 3urfeco Pad PA murnn u into ArruuAilury Ai4b !HAI IHE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS, I AL30 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. MI MuM 48 HOUR ADVANCE NOTICE REQUIRED/F/J(/ INSPECTIONS i TITLC tr. X�J�� V pA� 6 7 1 1 - CONTRACTORS SIGNATURE I ......p.••d.....1... ,.. . , ..__.a_....;... 1.....1.,.. t ..,. `.,.:..g I .{... ;.. ,,, ♦ .... { i, ..j...t64a l ..4 ._:.. t, i.._.1...,... ...,.......1......4....:.1...... ' ..1-• __-_ .. MAY1tufo...................:.......__......:;......!...-.;._...4 JOAQU� ..CQ N "�i .........- i--- ..`........ � ON NtAI.; 1......... I - ... 1, Application Accepted By DeslrucliDn In5Declion By COMMENTS PE SC I Received Chaekl Codes Into Bin /Cash _._r._.___._.... �..........._p......r...... ' ... 1 ER TMENT USE ON Dale hAXArea Dale Employee ID# Dale I 3ervloa Invoice It I Wall ID# 1 �' - e C i v e d T �i m�e 4M a Y. 9, 2018 7 2 1 AM IY , 3 4 9 6 6X-// WELL DESTRUCTION PERMIT