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0808'IN AVLB:II U06 8 qaj awil PaAiaaa� <br />I WELL DESTRUCTION PERMIT <br />PUBLIC WATER SYSTEM ❑ Yes I] No <br />SAN JOAQIIIN COON TY ENVrRONMENTAL HEALTH DEPT 1858 East Hazelton Avenite-STOCKTON CA OS205-6232 - 4209) 4684420 <br />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE IRMIFn <br />Joe AoDREss tv SCJ � r'_.� r-774 kxi r� % Jf <br />CROSS STREETJ���nU S141ZU 'J APN 4x/-7 /Z <br />OWNER ADDREss ZF.Oc u S 14 <br />-*�FOGk-&nr �a gS-DO7 <br />SILE! aL hD UsE APPLh:ATroN 11 e <br />�9- 4-77— 2783 � <br />tTE/ZIP ZS4o f CA `911b 7 <br />2aR- S-S�7-3-sst) <br />CONTRACTOR ADDRESS YD 1,a r( 44 <br />CITY/SrATEJLa L,,,dCI% <br />Cq. qG.A 3 4 <br />C-57 WELL DRILLING LICENSENUMBER 3�7 ��. <br />EXPIRATION DATE <br />-31-14 <br />PERFORATION CONTTIACTOR <br />Depth Casing jb� <br />PERFORATION CONTRACTOR AODREW <br />CITYISTATEMip <br />❑ C-57 Well Drilling <br />License Number <br />Expiration Date <br />Bureau of alcohol, Tobacco and Firearms - Users of High Explosives <br />License Number <br />Expiration Date---�g/��,+, <br />CHP Hazardous Material Tmnsponatiorr for Explosives <br />License Number <br />Expiration Date <br />San Joaquin County Sheriff -Coroner Explosives Application and Permit <br />License Number <br />Expiration Date <br />California Occupational Safety Health - Blaster <br />License Number <br />Expiration Date ei , <br />RFASON FOR DESTRUCTION ❑ Dry ❑ Replacernent Well ❑ Caved In ❑ Pit Well <br />■ Inactive 0 Test Hole <br />Detected/Suspected Well Water Cantaminant(s) <br />s`AN <br />Adjacent property with contamination (Address) <br />fn. <br />) <br />Known Soil /Water Contaminants at adjacent property <br />r.. _ , <br />EXISTING WELL CONSTtwciiorg DETAns ❑ Open Bottom ❑ Gravel Pack ❑ <br />Uncased ❑ Other <br />Well Log copy attac.ied ❑ Yes ■ No Grout Seal ❑ No ❑ Yes R below ground <br />surface (tgs) Hole Dlarneter Z. <br />Well Conductor Casing ` Qc . E No Depth of Conduety Casing ft bgs <br />Well CasingDiameter <br />,cher i <br />Diameter of Conductor Casing inches <br />Indies Total Depth �$�!: R Depth to Water R <br />Depth Casing jb� <br />of R logs <br />DmTRUCrrom S P ECIPFCA'ITO.N <br />Sealing Material from / 5a ' 11 bgs to ,& ftbgs Filler Material Cer),er,-,� <br />from I Ste, H bgs 19 <br />Well casing to be perforated by one of the following methods, from <br />to ft bgs <br />ft bgs to R bgs <br />❑ Mills Knife Number of cuts every fl and / or <br />❑ Explosives ❑ Detonating cord ❑ with projectiles every R <br />O without projectile <br />❑ other ❑ Detonating cord and boosters 13with projectiles every R <br />LJ wiihoutprojectile <br />Sealing Material Neat Cement (94 lb bag / 5-6 gal water) Sand Cement 10- sack rnixl7 gel water Bentonite Pellets <br />Bentonite (20% solids) Manufacturer Spec%sofids % Name <br />Specs on File Specs Submitted <br />Placement Method Pumped Free Fall Other <br />Seal Comptetlon Complete with Mushroom Cap 4-3 R bgs Complete to Existing Surface Pad <br />I HEREBY CERTIFY THAT I 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 I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />'!Vr <br />2In <br />10 <br />t,'d �Z9(�Z2260Z out sielp(] eoueimnd d0£:Z � 9l 80 qaj <br />