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pp: <br />5p,N JV <br />EtA` <br />Nep`�- <br />8b18'°N W E: 8 8106 '6 ')'eW anvil paAI;3;� <br />WELL DESTRUCTION ramiy lr <br />PLIBLJC WATER SYSTEM ❑ Yes ❑ No <br />SAN JOAQUIN COUNTY ENvIRONNIENTAL HEAL -nn DEPT 1868 East Hazelton Avenue-STOCKTON CA 9520"Z32 - (209) 4683420 <br />MnN-Prci ifinAR1 F PPOMIT r• a r I <br />Joe ADDRESS 5545 Sbippee Ln <br />CITYIZIP St ckton, CA 95212 <br />CROSS STREET 1 a III r a (, L APN <br />O PARCEL SITE AND USE APPUGN C <br />TIo <br />onINERRoberta Paulazo <br />PHOME — 07-0194 <br />2 5 V a l c e t a C t <br />a n v l e CA <br />OWNER ADDREss2 <br />_ <br />CITYISTATEMP <br />CONTRACTOR Pur7v�iance Drillers, <br />Inc. PHONE <br />CONTRACTOR ADDRESS C. C • B o x 64- <br />7209-887-3,1554 <br />C1,1sTATEm,. L i n d e n, A ()5236 <br />C-57 WELL DRa.uNO LICE/NSE NUMBER 377923 <br />ExPIRATmN DATE 7/31/19 <br />PERFORATION CONTRACTOR n / a <br />PHONE <br />PERFORATION CONTRACTOR ADDRESS <br />CITYISTATEMP <br />❑ C-57 Well Drilling <br />License Number Expiration Date <br />Bureau of Alcohol, Tobacco and Firearms- Users of High Explosives License Number Expiration Date <br />CHP Hazardous Material Transportation for Explosives <br />License Number Expiration Date <br />Sen Joaquin County Sheriff -Coroner Explosives Application and <br />Permit License Number Expiration Date <br />California Occupational Safety Health - Blaster <br />_ <br />Licensee Number Expiration Date <br />REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well <br />❑ Caved In ❑ Pit VJerl 0 Inactive ❑ Test Hole <br />Detected I Suspectee Well Water Contaminant(s) none <br />Adjacent property Wlh contamination (Address) <br />Known Sod I Aater contaminants at adjacent ptopery <br />Ex1ST1NG WELLCONS7RUCToN DETAILS a Open Bottom <br />❑ Gavel Pack ❑ Uncased ❑ 0-ber <br />Well Log copy attached ❑ Yes ja No Grout Seal ❑ No <br />❑ Yes _ R below grand surface (bgs) Hole Dlameter inches <br />Well Conductor Casing Yes IA No DepttiofConductor'Casing hbgs Diameter of Conductor Casing Inches <br />Well Casing Diameter i .nehes Total Depth _ ti <br />_ <br />Depth to Water V_fl Depth of Casing `7z�—hbgs <br />DESTRUCTION SPF.CTRICATIOi <br />Sealing Material from /01 fl bgs to 0 11 bgs Filler <br />Material ice- from I L ftbgs to ft <br />Well casing to be perforated byone of the following methods: <br />_ �— from fl bgs Io R bgs <br />❑ Mills Knife Number of ails every <br />Hand /or <br />❑ Explosives ❑ Detonating cord ❑ with projectiles every fl ❑ without projectile <br />❑ Detonating cord and boosters ❑ With projectiles every R ❑ Without projectile <br />❑ Other <br />Sealing Material Neat Cement ('9418 bag 15-6 gal vlate;) <br />Sand Cement 1 • sack mix l 7 gal water Bentonite Pellets <br />Bentonite (20% solids)�ufaeturer Spec % solids_% <br />Name Specs on File Specs Submitted <br />Placement Method Pumpe Free Fall <br />Other <br />searCompiotlon Comp hMushroomCap <br />ftbgs Complete to Existing Surface Pad <br />1 Ir1rKCtlT C7EK1U-T INAF I HAVE PREPARED 11H15 APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <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 I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />yr 'VImUon 24 DVAItiCE WTI CE REQUIRED FOR IIVSPECTI'ONS <br />CONTRACTORS SIGNATOR TITLECor S e c DATE 3/ 1/ 1 8 <br />o, <br />DT�MsN DAG, <br />l_ <br />Application Accepted By _ <br />Destruction Inspection By <br />COMMENTS PC4Gt% <br />r -i <br />�o <br />ARTMENT USE ON Y <br />Date Area <br />Date Employee IDS —f <br />PE SC Received CheckfM Amount Date Permit! In tY Wefl IDC <br />Codes Info Ey'— Cash Remitted Service R uest4 <br />I <br />101507 76 (/ 1 - 4 -7 / 1 C�73�— <br />Z'd <br />WELL DESTRUCTION PERMIT <br />tasDT � Jai (P 6 'VL5£L9860Z oul sjelp (] soueinind e9Z:60 9 � ZO JeW <br />