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0808'°N WB:[[ 2[H -8 'q;J ;Lail p;Ai;0;� <br />WELL DESTRUCTION PERMIT <br />Ai <br />y; <br />n <br />PUBLIC WATER SYSTEM Q Yes ❑ ND <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1668 East Hazelton Avenue-STOCKTON CA 95205-6232 - (209) 468.3.120 <br />NON-REFUNDABLE PERMIT (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />�� f L !IC�ALL <br />/ <br />JOB AooREss _J Inc- t43Okr , Yr Cmc/LP c_J-fy Ck-4cr1. (L} q$10'7 <br />1..�men-l' from IS�r 8 bgs to 10 It bgs <br />Well casing to he 0e rated: by one of the rollowiag mothods: <br />CROSS STRffT` APNt..-/ �%3 PaacELS�-- aL <br />c <br /><_ <br />/ND+IUSSrEAPP�]UCATIONB <br />(r <br />OWNER �n ego t7 I;'GS [ILi 4erwr] L%7tttL:'-1 PHONE 4- at7 I !— G �lp3 <br />ft ❑ without projeclile <br />13Detonating cord and boosters D with projediles every <br />OWNERAooREss_CJO :D /aS-1?w CnYI$TATEl21P cC�4'D71(Ca 9s�e7 <br />❑ Otllar <br />CONTRACTOR�uf7ri�ljC��' /��Jl/1el �ldYS r�A-1t PHONE_ �c'i-//FS <br />Bentonite 120% solids) Manufacturer Spec % solids _% Name <br />Specs on File Specs Submitted <br />^J//p <br />CONTRACTORADDRFSS 7 z)rr+'% CITYISTATEMP_f -InIC/C17 <br />Other <br />Seat Completion Complete with Mushroom Cap 90.3 fl bgs <br />CST WELL DRILLUIG UCEIJSE NUMBER 3 r �� _ EXPIRATION DATE <br />PERFORATDN C DNTRACTOR A PHONE <br />PERFORATION CONTRACTOR ADDRESS CITYISTATrJZIP <br />I <br />PE SC Received <br />❑ C-57 Well Drilling License Number Expiration Cate <br />Bureau of Alcohol, Tobacco and Firearms - Users of High Explosives License Number Expiration Dale <br />Date <br />Cash bmtvie <br />Service Rmuest 4 <br />CHP Hazardous Material Transportation for Explosives License Number Expiration Cale <br />e� <br />ENI <br />San Joaquin County Sheriff -Coroner Explosives ApplicaUon and Penn it license Number Expiration Dale <br />t� <br />Catifamia Occupational Safety Health . Blaster License Number Expiration Dateyw=ut <br />E[ <br />REASON FOR DESTRUCTION ❑ Dry ❑ Replacement Well ❑ Caved In ❑ Pitwell ■ Inactive ❑ Te s N <br />i <br />Detected I Suspected Well Water Contaminants) <br />2016 <br />Adjacentpropertywilhcontamination (Address) <br />WELL DESTRUCTION PERMIT <br />Known -Soil [Water cordaminants at adjacent property_ ' SAN Ir)A <br />OUNI <br />EXISTING WELL CONSTRUCTON DETAI ❑ Open Bottom ❑ Gravel Pack O Unased ❑ Other HI( <br />� <br />Log copy attached 13Yes it No Grout Sear ❑ No ❑ Yes fl below ground surface (bgs) Hole Diameter r '•Tj ,ches <br />rM <br />Well <br />Ek <br />Well Conductor Casing ❑ "ac i No Depth of Cand��ctp Caang It Dgs Diameter of Conductor Caslog inches <br />i <br />Well Casing Diameter—* inches Total Depth,- 2 11 Depth to Water It Depth of Gsing_-> fl bgs <br />UFSMUCTiON SPECIFICATIO <br />Z <br />-- — <br />Sealing Material from f R bgs to � tt bgs Filler Material <br />1..�men-l' from IS�r 8 bgs to 10 It bgs <br />Well casing to he 0e rated: by one of the rollowiag mothods: <br />_from R bgs to li bgs <br />❑ Mills Kittle Number of cuts every fl and / or <br /><_ <br />❑ Explosives ❑ Detonating cord ❑ with projectiles every <br />ft ❑ without projeclile <br />13Detonating cord and boosters D with projediles every <br />ft ❑ without projectile <br />❑ Otllar <br />Sealing Material Neat Cement (941b bag/5-6 gal water) Sand Cement (q- Sack mix 17 gal water Bentonite Pellets <br />Bentonite 120% solids) Manufacturer Spec % solids _% Name <br />Specs on File Specs Submitted <br />Placement Method Pumped Free Fall <br />Other <br />Seat Completion Complete with Mushroom Cap 90.3 fl bgs <br />Complete to Existing Surface Pad <br />i MtKttlT UtKIIFY THAT 1 HAVE PREPARED THIS 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 t AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />MINVltY 24 A ANCE NOTICE REQUIRED FOR INSPECTIONS <br />CONTRACTORS SIGNATURE TITLE <br />3' <br />-r <br />Fri <br />M <br />t3o <br />O <br />Oo <br />� <br />M <br />��y <br />1�� <br />01 <br />M <br />C <br />®N <br />9'd �ZSU2960Z out sjellp(] ecuepund d0£:Z6 96 80 qac i� <br />Jr <br />7 <br />PARTMENT USE <br />ON Y <br /><_ <br />Application Accepted BY <br />AftDate <br />Area C <br />Destrucllor• inspecti n y <br />Emtoyee I <br />COMMVYTS <br />PE SC Received <br />Checfdtl AmountPermit/ <br />Info El <br />Date <br />Cash bmtvie <br />Service Rmuest 4 <br />Invoice d Well IDM <br />EHD4&08 <br />1111115077 <br />WELL DESTRUCTION PERMIT <br />-r <br />Fri <br />M <br />t3o <br />O <br />Oo <br />� <br />M <br />��y <br />1�� <br />01 <br />M <br />C <br />®N <br />9'd �ZSU2960Z out sjellp(] ecuepund d0£:Z6 96 80 qac i� <br />