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Apr.27L2018 07:01 AM Canepa and Sons 209 532 4819 PACE. 2/ 12 <br />s <br />WELL DESTRUCTION PERMIT <br />PUBLIC WATER SYSTCM [--] Ycs ❑ No <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1800 east Hnzollon Avanuo • STOCKTON CA oms-B232 • (200) 408-3420 <br />Nnkl_Qcc„unnor v ban u,. <br />JOB ADDROaB� ��- �/�LrY� r� <br />--- _�� ••••� ••... ..,. ,....-mow rvnv Jnr-- r <br />CITYIZI P1CHK rnVm VAIC Iy�UEI) <br />0• <br />1!- <br />CROBB STREET k6T0IV +MZ <br />_ <br />_ <br />PARCEL SIZE& LAND UBB APPLICATI%{' <br />OWNER G 440 <br />PIIorIe - Ell (: C <br />OWNORADORDBe <br />-'49 CITY/STAT371/ <br />CONTRACTORC&A.ILIP O ,I <br />TEE/ZIP/.��N/I <br />//V[ . PIIONtl V'L ��I ra 1- �` // <br />6(�r <br />CONTRACTOR ADORQBB ��/✓Ol C4- <br />r-1 r4- Cr ..i <br />0TYIBTATBIZIP <br />C•S ELL DRILLING LtCtlNBa N <br />w <br />McER 0��,/�9� /^ E%PIRATI(Of/I�DATII7'-1 a / <br />PERFORATION CONTRACTDR Il LP44 <br />r9yy ,' <br />:-/?-Y <br />S W Seevice PNONE l -I'���,��� <br />PERFORATION CONTRACTOR ADDRRes 1 7 <br />�l�....(e)[ <br />G <br />N e5 fWe CITYISTAYIYZIP T�714C'�1 Pl 933 7. <br />C-57 Well Delltloo <br />Bureau of Alcotlol, Tobacco and Flre <br />License Numbor —+2--, '74q E% Irallon Dalo <br />1"B • Utloru of Hlph Exploelves Lloonso Number O 1M D Irallon Dais I - r - zi <br />CHP Hazardous Motorist Tftu+uporlal <br />n for Exploelvoa Llconso Numbor Expiration pato <br />San JongUln County Shorlff•Coronor <br />xploetvou Application and Purnell Llconso Number •OI Expiration Dale T_ 9 <br />California Occupollonol Safely Health <br />- Blaster Llcenoe Numbor 92tel ` Gxplratlon Dale <br />REABQN FOR DYsYAUrTION ❑ Dry <br />p Replacemenl Well Q Caved In ❑ PII Wult Inocllvo ❑ Tool Holo <br />Delacled / Suspeclad Wall Water Conlaml <br />ent(a) <br />Adjacent property with Conlelnlnallon (Ad <br />lrose)-- . <br />Known Sol] / Walor aonlaminn nts AL arl)ac <br />nI pmhArly__-_. <br />]EXIOTIMP Wou. QQNsTamIoN DETAILO <br />K Opell 801101" ❑ Oro Vel Pack ❑ Uncased ❑ Other. <br />Woll Log wpy ulluchad ❑ Yee No <br />Wall Conductor Casino Yon <br />Grout Boal O Nu ❑ Yue If bolow ground sudacu (bgu) Holo pinmofor Inchuu <br />No <br />Wall CaelnD Dlemolor j,�. <br />Depth of Condu�cthor C -Ing �h bps Olontotor of Conductor Casing _ Inchoa <br />__InChoe <br />Biel Doplh 17- _II Doplh to Wnlor _ II Capin of CasinH f �l.QR bus <br />ff P_'fflkL TfflN SPECIPWA'ITIIN <br />Sonling Mnlorlol from a.-. ,(I boa to <br />17.0 R bps FIIIor Malarial , from 11 boo to. bqa <br />Wall casing to bo Darfornled by <br />,...._..,._...._II <br />__ _ Irom _ It hOu to ll Noll <br />❑ MIIIs Knlla _ --. -.Numbor n <br />Explosives ❑ Dolonalln0 cord <br />ruls ovary It find / nr <br />❑ <br />Dotonaling cord and L <br />with projoclllas ovary it ❑ without prn)nrtlln <br />oo9(oro )( will) projectiles every (b_ Il El <br />13 Olhor <br />W11110141 projoclllo <br />Sonitng Mntorinl Nool Courant t'941b <br />g /S -d pal walae) Band CamoM ID -3 400(mix /'[gal Welor Bontonllo Pollole <br />Sonlonito (20% solids) MDnuracl <br />Placomont Molhod umped <br />ror Spuu % uollde % Nurnu Spuuo on Filo Space Subndl(ud <br />Free Fall Other <br />Boal Complallon Complolo Will) Mushroom <br />Can __.. 11 bog Complslo to existing Surface Pad <br />I HEREBY CERTIFY THAT I HAVE PREPARED <br />THIS APPLICATION AND TPIAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN <br />JOAQUIN COUNTY ORDINANCES, STATE <br />LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IB <br />CURRENT AND ACTIVE WITH THE CALIF <br />RNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITII ALL <br />WORKERS COMPENSATION LAWS. <br />IfAUM 48 <br />MR ADVANCE NOTICE REQUIRED P ri INSPECTIONS <br />CONTRACTOR8 SIONAYURa <br />Tae ,Gef/V NT' DATE, 4f <br />�4�,... <br />1, <br />0. <br />b�D <br />O <br />I <br />itI <br />r. <br />r <br />I, <br />EP MENT USE D / <br />Appllcallon Accoptod By <br />Ordu lkz� Arou <br />Doelruollnn Inapocllon BY <br />__ n DDIo Employ 11 IpIA <br />COMMEN'rS <br />PE <br />8C <br />I Raoolvad <br />Chocklf! <br />Amount <br />od <br />Onto <br />pormlt! <br />S ry co Ro Uosl N <br />Involoo 9Wall <br />IDY <br />- <br />— <br />...:. . <br />C -HO m e I �7-4701-779. WELL DEBTRUC'I'ION FUIennlT <br />4�Re�elved Tlme'"'Apr. 21. 2018 7;53iM No, 3445 l `/�H� <br />PA, <br />rMFN <br />,q CF�V�O <br />2418 <br />/NCO <br />FNT <br />